title: Efficacy and safety of the low-molecular weight heparin enoxaparin compared with unfractionated heparin across the acute coronary syndrome spectrum: a meta-analysis.
abstract: OBJECTIVE
  To determine whether the low-molecular weight heparin enoxaparin remains favourable when compared with unfractionated heparin (UFH) among patients with acute coronary syndromes (ACS) when incorporating efficacy and safety of these adjunctive therapies using a net clinical endpoint.
  
  
  RESULTS
  We performed a meta-analysis of randomized trials of enoxaparin vs. UFH in ST-elevation-MI (STEMI) or non-ST-elevation-ACS (NSTEACS) (n = 49,088 patients in 12 trials). The net clinical endpoint was defined as death, MI, or major bleeding by 30 days. Death or myocardial infarction (MI) was significantly reduced with enoxaparin when compared with UFH (9.8 vs. 11.4%, OR 0.84, P < 0.001). The net clinical endpoint occurred less frequently with enoxaparin than UFH (12.5 vs. 13.5%, OR 0.90, P = 0.051). Major bleeding was higher with enoxaparin (4.3 vs. 3.4%, OR 1.25, P = 0.019). Among STEMI trials, the net clinical endpoint was significantly lower with enoxaparin (OR 0.84, P = 0.015), but there was no difference in NSTEACS trials (OR 0.97).
  
  
  CONCLUSIONS
  When compared with UFH, enoxaparin was associated with superior efficacy as adjunctive antithrombin therapy among >49 000 patients across the ACS spectrum. Although bleeding was increased with enoxaparin, this increase was offset by a reduction in death or MI. The net clinical benefit in favour of enoxaparin was evident among the STEMI population and was neutral among the NSTEACS population.
authors.affiliation: TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 350 Longwood Avenue, First Floor, Boston, MA 02115, USA. smurphy@perfuse.org
authors.forename: Sabina A
authors.initials: SA
authors.lastname: Murphy
authors.forename: Charles Michael
authors.initials: CM
authors.lastname: Gibson
authors.forename: David A
authors.initials: DA
authors.lastname: Morrow
authors.forename: Frans
authors.initials: F
authors.lastname: Van de Werf
authors.forename: Ian B
authors.initials: IB
authors.lastname: Menown
authors.forename: Shaun G
authors.initials: SG
authors.lastname: Goodman
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Mahaffey
authors.forename: Marc
authors.initials: M
authors.lastname: Cohen
authors.forename: Carolyn H
authors.initials: CH
authors.lastname: McCabe
authors.forename: Elliott M
authors.initials: EM
authors.lastname: Antman
authors.forename: Eugene
authors.initials: E
authors.lastname: Braunwald
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy*; D000991:Antithrombins / Q000627:therapeutic use*; D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D017984:Enoxaparin / Q000627:therapeutic use*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy*; D016032:Randomized Controlled Trials as Topic; D055502:Secondary Prevention; D016896:Treatment Outcome
chemical_list: D000991:Antithrombins; D017984:Enoxaparin; D005343:Fibrinolytic Agents