Low molecular weight heparins in the management of unstable angina/non-Q-wave myocardial infarction.
The safety and efficacy of enoxaparin, dalteparin, and nadroparin have been studied in five major trials in the treatment of unstable angina/non-Q-wave myocardial infarction (UA/NQWMI). To date, enoxaparin is the only low molecular weight heparin (LMWH) to have demonstrated superiority over unfractionated heparin (UFH) in preventing clinical endpoints in this indication, including a composite triple endpoint of death, myocardial infarction, and need for revascularization. Equivalent clinical benefits were obtained with enoxaparin in two major phase III randomized trials (ESSENCE, TIMI 11B), and were not accompanied by any increased risk of major hemorrhage. A meta-analysis of data from TIMI 11B and ESSENCE demonstrated that enoxaparin was associated with a 20% reduction in death and serious cardiac ischemic events. The benefit appeared within a few days of starting therapy, was sustained through 43 days, and has been confirmed to persist one year after treatment. By contrast, in similar trials, neither dalteparin nor nadroparin was shown to be superior to UFH in the management of acute coronary syndromes. The benefit of enoxaparin demonstrated in the ESSENCE study extended across patient subgroups and was accompanied by substantial cost savings. Differences in trial design prevent direct comparisons between products, but prescribing decisions should be based on the available clinical trial evidence.
Cohen
M
M
Cardiac Catheterization Laboratories, Hahnemann Hospital, Philadelphia, Pennsylvania 19102, USA.
D000789:Angina, Unstable / Q000188:drug therapy*; D000818:Animals; D002986:Clinical Trials as Topic; D019468:Disease Management; D004341:Drug Evaluation; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use*; D006801:Humans; D009203:Myocardial Infarction / Q000188:drug therapy*
D006495:Heparin, Low-Molecular-Weight