title: Non-ST-segment elevation acute coronary syndrome in patients with renal dysfunction: benefit of low-molecular-weight heparin alone or with glycoprotein IIb/IIIa inhibitors on outcomes. The Global Registry of Acute Coronary Events.
abstract: OBJECTIVE
  To determine whether low-molecular-weight heparin (LMWH)+glycoprotein (GP) IIb/IIIa inhibitors provide greater benefit than unfractionated heparin (UFH)+GP IIb/IIIa inhibitors, irrespective of renal status.
  
  
  RESULTS
  Patients in the Global Registry of Acute Coronary Events (GRACE) were divided into three groups according to creatinine clearance (CrCl): normal renal function (CrCl >60 mL/min), moderate renal dysfunction (30<CrCl< or =60 mL/min), and severe (CrCl< or =30 mL/min) renal dysfunction. Data were analysed from 11 881 patients with acute coronary syndrome (ACS). Patients with moderate (n=3705) or severe (n=982) renal dysfunction were at higher risk of adverse outcomes than those with normal renal function. Decreasing CrCl was an independent predictor of mortality at 30 days and in-hospital major bleeding. LMWH+GP IIb/IIIa inhibitors were used significantly less frequently in patients with severe (2.0%) or moderate (3.1%) renal dysfunction than in those with normal function (3.9%, P=0.0056). LMWH alone was more beneficial than UFH alone, irrespective of renal status. LMWH alone was an independent predictor of 30 day survival [odds ratio (OR) 0.56; 95% confidence interval (CI) 0.43-0.73] and lower risk of in-hospital bleeding (OR 0.66; 95% CI 0.48-0.92). Bleeding rates were significantly lower with LMWH+GP IIb/IIIa inhibitors than those with UFH+GP IIb/IIIa inhibitors. Use of UFH+GP IIb/IIIa inhibitors was an independent predictor of bleeding (OR 2.02; 95% CI 1.42-2.90) compared with UFH alone.
  
  
  CONCLUSIONS
  In patients with renal dysfunction and non-ST-segment elevation ACS, bleeding complications are more frequent and outcomes appear worse in individuals treated with UFH compared with LMWH. Combination therapy with LMWH and GP IIb/IIIa inhibitors appears to be better tolerated than with UFH and GP IIb/IIIa inhibitors.
authors.affiliation: Department of Cardiology, Centre Hôpital Pitié-Salpêtrière, Bureau 2-236, 47, Boulevard de l'Hôpital, 75013 Paris, France.
authors.forename: Jean-Philippe
authors.initials: JP
authors.lastname: Collet
authors.forename: Gilles
authors.initials: G
authors.lastname: Montalescot
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Agnelli
authors.forename: Frans
authors.initials: F
authors.lastname: Van de Werf
authors.forename: Enrique P
authors.initials: EP
authors.lastname: Gurfinkel
authors.forename: Jose
authors.initials: J
authors.lastname: López-Sendón
authors.forename: Christopher V
authors.initials: CV
authors.lastname: Laufenberg
authors.forename: Martin
authors.initials: M
authors.lastname: Klutman
authors.forename: Neelam
authors.initials: N
authors.lastname: Gowda
authors.forename: Dietrich
authors.initials: D
authors.lastname: Gulba
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D003327:Coronary Disease / Q000188:drug therapy* / Q000401:mortality; D004359:Drug Therapy, Combination; D005260:Female; D006470:Hemorrhage / Q000209:etiology / Q000401:mortality; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use*; D006801:Humans; D007674:Kidney Diseases / Q000150:complications* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000627:therapeutic use*; D011446:Prospective Studies; D013223:Statistics as Topic; D013577:Syndrome; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight; D019039:Platelet Glycoprotein GPIIb-IIIa Complex