title: Angiographic and clinical outcomes in patients receiving low-molecular-weight heparin versus unfractionated heparin in ST-elevation myocardial infarction treated with fibrinolytics in the CLARITY-TIMI 28 Trial.
abstract: BACKGROUND
  Low-molecular-weight heparin (LMWH) offers pharmacological and practical advantages over unfractionated heparin (UFH). Whether these advantages translate into greater infarct-related artery patency and fewer adverse clinical events in patients with ST-elevation myocardial infarction (STEMI) receiving fibrinolytic therapy remains under study.
  
  
  RESULTS
  We compared angiographic and clinical outcomes in patients treated with LMWH (n=1429) versus UFH (n=1431) in CLARITY-TIMI 28, a randomized trial of clopidogrel versus placebo in STEMI patients aged 18 to 75 years undergoing fibrinolysis. After comprehensive adjustment for baseline characteristics, therapeutic interventions, and a propensity score, treatment with LMWH was associated with a significantly lower rate of a closed infarct-related artery or death or myocardial infarction before angiography (13.5% versus 22.5%, adjusted OR 0.76, P=0.027). Treatment with LMWH was also associated with a significantly lower rate of cardiovascular death or recurrent myocardial infarction through 30 days (6.9% versus 11.5%, adjusted OR 0.68, P=0.030). The lower event rates were observed in patients allocated to clopidogrel and in those who underwent percutaneous coronary intervention. Rates of TIMI major bleeding through 30 days (1.6% versus 2.2%, P=0.27) and intracranial hemorrhage (0.6% versus 0.8%, P=0.37) were similar in the LMWH and UFH groups. Patients who received both clopidogrel and LMWH, in addition to a standard fibrinolytic and aspirin, had a particularly high rate of infarct-related artery patency (90.9%) and particularly low rates of cardiovascular death (3.2%), recurrent myocardial infarction (3.0%), and major bleeding (1.8%).
  
  
  CONCLUSIONS
  In patients with STEMI receiving fibrinolytic therapy, use of LMWH with other standard therapies, including clopidogrel and aspirin, is associated with improved angiographic outcomes and lower rates of major adverse cardiovascular events.
authors.affiliation: Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. msabatine@partners.org
authors.forename: Marc S
authors.initials: MS
authors.lastname: Sabatine
authors.forename: David A
authors.initials: DA
authors.lastname: Morrow
authors.forename: Gilles
authors.initials: G
authors.lastname: Montalescot
authors.forename: Mikael
authors.initials: M
authors.lastname: Dellborg
authors.forename: Jose L
authors.initials: JL
authors.lastname: Leiva-Pons
authors.forename: Matyas
authors.initials: M
authors.lastname: Keltai
authors.forename: Sabina A
authors.initials: SA
authors.lastname: Murphy
authors.forename: Carolyn H
authors.initials: CH
authors.lastname: McCabe
authors.forename: C Michael
authors.initials: CM
authors.lastname: Gibson
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Cannon
authors.forename: Elliott M
authors.initials: EM
authors.lastname: Antman
authors.forename: Eugene
authors.initials: E
authors.lastname: Braunwald
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001241:Aspirin / Q000627:therapeutic use; D000077144:Clopidogrel; D017023:Coronary Angiography; D003328:Coronary Thrombosis / Q000517:prevention & control; D004359:Drug Therapy, Combination; D004562:Electrocardiography; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006470:Hemorrhage / Q000139:chemically induced; D006493:Heparin / Q000008:administration & dosage* / Q000633:toxicity; D006495:Heparin, Low-Molecular-Weight / Q000008:administration & dosage* / Q000633:toxicity; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D015425:Myocardial Reperfusion; D055502:Secondary Prevention; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000627:therapeutic use; D016896:Treatment Outcome; D014654:Vascular Patency / Q000187:drug effects
chemical_list: D005343:Fibrinolytic Agents; D006495:Heparin, Low-Molecular-Weight; D006493:Heparin; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin