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Low-Molecular-Weight Heparins in the Treatment of Acute Coronary Syndromes

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Low-Molecular-Weight Heparins in the Treatment of Acute Coronary Syndromes REVIEW ARTICLE Low-Molecular-Weight Heparins in the Treatment of Acute Coronary Syndromes Alexander G. G. Turpie, MD; Elliott M. Antman, MD latelet aggregation and activation of coagulation are key events in the development of acute coronary syndromes. Patients with an acute coronary syndrome are at high risk of death or myocardial infarction, and hence there is a strong rationale for the use of antithrombotic agents. Heparin has been shown to reduce the risk of death or myocar- Pdial infarction in aspirin-treated patients with acute coronary syndromes, but it has a number of limitations, including the need for regular monitoring and the risk of hemorrhage and thrombo- cytopenia. Low-molecular-weight heparins offer a number of practical and clinical advantages over unfractionated heparin, such as higher bioavailability and administration by subcutaneous injec- tion. Several low-molecular-weight heparins are available that differ in their biochemical and phar- macologic properties, and it is not possible to predict their clinical efficacy from their pharmaco- logic profile. The decision regarding the use of a specific low-molecular-weight heparin should be based on the efficacy and safety data available for each product. In clinical trials comparing low- molecular-weight heparin with heparin, only enoxaparin sodium has been shown to reduce the risk of coronary events in patients with non–ST segment elevation acute coronary ischemia. Arch Intern Med. 2001;161:1484-1490 Clinical and pathologic studies have high- gina and non–Q wave MI indicates that the lighted the importance of plaque rupture culprit artery is only partially or intermit- and platelet aggregation in the pathogen- tently occluded or that a rich collateral cir- esis of the acute coronary syndromes (ACS) culation exists. Nonocclusive intracoro- of Q wave myocardial infarction (MI), nary thrombi are present in 85% or more non–Q wave MI, and unstable angina.1,2 Fol- of patients with non–ST segment elevation lowing rupture of an atherosclerotic plaque, ACS,1 and autopsy studies in such patients tissue factor in the lipid core is exposed to suggest that vascular occlusion that leads to circulating factor VIIa, resulting in the for- MI or sudden death results from repeated mation of a tissue factor–factor VIIa com- episodes of plaque fissure and mural throm- plex and generation of factor Xa.3,4 This leads bosis.2,7 Such lesions are often not stabi- ultimately to the formation of large amounts lized by therapy focused only on symptom of thrombin, resulting in fibrin deposition relief, but continue to progress and cause and platelet activation.5,6 Electrocardio- ischemic events throughout several graphic evidence of ST segment elevation months.8,9 As a result, patients with ACS are indicates that the culprit artery is com- at increased risk of death and MI. Death or pletely occluded and that the patient will MI occurs in 9% to 11% of patients with most likely subsequently develop ST seg- non–ST segment elevation ACS within 4 to ment elevation MI. The absence of ST seg- 6 weeks after the onset of symptoms,10,11 and ment elevation in patients with unstable an- recurrent angina occurs in up to 64% of pa- tients who are hospitalized.12 From the Department of Medicine, McMaster University, Hamilton, Ontario The key roles of thrombin genera- (Dr Turpie), and Cardiovascular Division, Department of Medicine, Brigham and tion and platelet activation in the patho- Women’s Hospital, Boston, Mass (Dr Antman). genesis of ACS create a strong rationale for (REPRINTED) ARCH INTERN MED/ VOL 161, JUNE 25, 2001 WWW.ARCHINTERNMED.COM 1484 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 the use of antithrombotic agents in need to be continuously adjusted that a number of other actions con- the management of these condi- according to the activated partial tribute to the antithrombotic effects tions. Current management guide- thromboplastin time, and even with of these agents. Indeed, it is now rec- lines13 recommend that patients with adjustment dosing is often subthera- ognized that up to 70% to 80% of the unstable angina should receive as- peutic, making long-term treat- material contained in a dose of pirin, at doses between 75 and 325 ment impractical.21 This is an im- LMWH acts via mechanisms that are mg, unless clear contraindications portant issue because long-term independent of antithrombin.28,29 are present. These guidelines are treatment may be beneficial in pa- Such mechanisms include the fol- supported by a 1983 study14 in which tients with ACS: the risk of ische- lowing: release of tissue factor path- the incidence of death or MI in men mic events remains significant for way inhibitor (TFPI), interaction with unstable angina who were several weeks after the initial epi- with heparin cofactor II, inhibition treated with 325 mg/d of aspirin sode,21 and the coagulation system of procoagulant effects of leuko- compared with placebo was re- can remain activated for several cytes, promotion of fibrinolysis, pro- duced by 51% (P=.0005). The risk months.22,23 Furthermore, UFH treat- tein binding, and effects on vascu- of nonfatal MI was also signifi- ment is associated with significant lar endothelium (receptor mediated cantly lower in aspirin-treated pa- complications, including hemor- and receptor independent). In par- tients than in the placebo group and rhage,19 reactivation of the thrombotic ticular, the effects of LMWHs on mortality was reduced, although not process within hours of discontinu- TFPI have attracted increasing at- significantly. Subsequently, several ing treatment,24 heparin-induced tention. Tissue factor pathway in- large controlled trials in patients with thrombocytopenia,25 and a rebound hibitor is a glycoprotein that inhib- unstable angina treated with aspi- increase in thrombotic activity and its the factor VIIa–tissue factor rin at daily doses between 75 and clinical events after discontinuation complex by forming a quaternary 325 mg demonstrated a significant of treatment.22,26 complex with the factor VIIa– reduction in death, MI, or both.15-18 Low-molecular-weight hepa- tissue factor complex and factor Xa.30 Unfractionated heparin (UFH) rins (LMWHs) offer a number of po- In addition, it inhibits factor Xa by has also been used, alone or in com- tential advantages over UFH in the binding at or near the active site30 bination with aspirin, in patients management of ACS. They have a and has a variety of other antithrom- with unstable angina, since it inhib- higher ratio of anti-Xa–anti-IIa ac- botic effects, which include the fol- its thrombin-induced platelet aggre- tivity than UFH (thereby offering a lowing: inhibition of tissue factor– gation and fibrin formation and thus potentially greater antithrombotic ef- mediated activation of platelets and prevents propagation of an estab- fect), and as a result of the cascad- macrophages, inhibition of factor Xa lished thrombus. Indeed, combina- ing nature of the coagulation sys- and elastase, multidomain inhibitor tion treatment with aspirin and UFH tem, inhibition of a small quantity of protease generation, interactions has previously been recommended of factor Xa prevents the formation with low-density lipoproteins, inter- for patients with unstable angina or of considerably larger amounts of actions with vascular endothelium, non–ST segment elevation MI be- thrombin.6 Other potential advan- modulation of endogenous gly- cause of the accumulating trial evi- tages include a high bioavailability cosaminoglycans, neutralization of dence showing the benefit of such after subcutaneous administration; endogenous tissue factor, and pos- treatment.13 In an early clinical trial, more predictable anticoagulant ef- sible regulatory functions.29 Both UFH treatment with UFH was associ- fect, which avoids the need for thera- and LMWHs release TFPI from the ated with reduced incidences of MI peutic monitoring; and decreased vascular endothelium.30,31 and refractory angina, compared sensitivity to platelet factor 4.6 Al- The LMWHs are prepared by a with placebo, and UFH tended to re- though these features are common variety of chemical and enzymatic duce the incidence of MI to a greater to all LMWHs, it is important to note depolymerization techniques, re- extent than aspirin.17 In a subse- that LMWHs are a heterogeneous sulting in marked differences in their quent extension of this study, the in- group of compounds that differ physical and biochemical proper- cidence of MI was significantly lower markedly in their physical and phar- ties.27,28,32 Such variations in biologi- in UFH-treated patients than in pa- macologic properties. Thus, each cal activity among LMWHs include tients receiving aspirin (0.8% vs LMWH must be tested in each clini- the following: variations in affinity 3.7%; P=.035).19 A meta-analysis of cal indication and the results ob- for coagulation proteins (eg, anti- published trials found that the risk tained with one LMWH do not ap- thrombin, platelet factor 4, fibrino- of death or MI was reduced by 33% ply to another. gen, protamine, factor VIII), differ- in patients with unstable angina who ences in binding to endothelial cells received both aspirin and UFH, com- LMWHs IN ACS: and blood cells, differences in pro- pared with those who received as- PHARMACOLOGIC tease inhibition, and differences in pirin alone, which suggests that the CONSIDERATIONS bioavailability and pharmacokinet- addition of heparin provides fur- ics. Typically, LMWHs have mo- ther benefit in aspirin-treated pa- The potency of LMWH is normally lecular weights between 4000 and tients.20 However, the use of UFH is expressed in terms of the anti-Xa ac- 8000 kd, but the available prepara- associated with significant disad- tivity.27,28 However, with increasing tions differ in their molecular weight vantages. The anticoagulant effect understanding of the mechanisms of distribution: some show a wide dis- produced is unpredictable and doses action of LMWHs, it has become clear tribution of low- and high-molecu- (REPRINTED) ARCH INTERN MED/ VOL 161, JUNE 25, 2001 WWW.ARCHINTERNMED.COM 1485 ©2001 American Medical Association.
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