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Previous Volume 354:1477-1488 April 6, 2006 Number 14 Next

	Full Text PDF PDA Full Text PowerPoint Slide Set Editorial by Gibbons, R. J. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear PubMed Citation

ABSTRACT

Background Unfractionated heparin is often used as adjunctive therapy with fibrinolysis in patients with ST-elevation myocardial infarction. We compared a low-molecular-weight heparin, enoxaparin, with unfractionated heparin for this purpose.

Methods We randomly assigned 20,506 patients with ST-elevation myocardial infarction who were scheduled to undergo fibrinolysis to receive enoxaparin throughout the index hospitalization or weight-based unfractionated heparin for at least 48 hours. The primary efficacy end point was death or nonfatal recurrent myocardial infarction through 30 days.

Results The primary end point occurred in 12.0 percent of patients in the unfractionated heparin group and 9.9 percent of those in the enoxaparin group (17 percent reduction in relative risk, P<0.001). Nonfatal reinfarction occurred in 4.5 percent of the patients receiving unfractionated heparin and 3.0 percent of those receiving enoxaparin (33 percent reduction in relative risk, P<0.001); 7.5 percent of patients given unfractionated heparin died, as did 6.9 percent of those given enoxaparin (P=0.11). The composite of death, nonfatal reinfarction, or urgent revascularization occurred in 14.5 percent of patients given unfractionated heparin and 11.7 percent of those given enoxaparin (P<0.001); major bleeding occurred in 1.4 percent and 2.1 percent, respectively (P<0.001). The composite of death, nonfatal reinfarction, or nonfatal intracranial hemorrhage (a measure of net clinical benefit) occurred in 12.2 percent of patients given unfractionated heparin and 10.1 percent of those given enoxaparin (P<0.001).

Conclusions In patients receiving fibrinolysis for ST-elevation myocardial infarction, treatment with enoxaparin throughout the index hospitalization is superior to treatment with unfractionated heparin for 48 hours but is associated with an increase in major bleeding episodes. These findings should be interpreted in the context of net clinical benefit. (ClinicalTrials.gov number, NCT00077792 [ClinicalTrials.gov] .)

Source Information

From the Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (E.M.A., D.A.M., C.H.M., S.A.M., E.B.); the Department of Emergency Cardiology, Cardiology Research Center, Moscow (M.R.); the National Institute of Cardiology (Z.S.) and the Postgraduate Medical School, Department of Cardiology, Grochowski Hospital (A.B.) — both in Warsaw, Poland; Hospital Universitario La Paz, Madrid (J.L.L.-S.); Dokuz Eylul Universitesi, Izmir, Turkey (S.G.); International Clinical Development, Sanofi-Aventis, Bridgewater, N.J. (F.J.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and the University of Edinburgh, Cardiovascular Research, Edinburgh (K.A.A.F.).

This article was published at www.nejm.org on March 14, 2006.

Address reprint requests to Dr. Antman at the TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115, or at eantman{at}rics.bwh.harvard.edu.

Full Text of this Article

Related Letters:

Enoxaparin versus Unfractionated Heparin in ST-Elevation Myocardial Infarction
DeCarolis D. D., Sleight P., Eikelboom J. W., Bassand J.-P., Antman E. M., Braunwald E.
Extract | Full Text | PDF  
N Engl J Med 2006; 354:2830-2832, Jun 29, 2006. Correspondence

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