The Role of Enoxaparin Across ACS Spectrum

Transcription

1 SYP.ENO The Role of Enoxaparin Across ACS Spectrum dr. Hariadi Hariawan, Sp.PD, Sp.JP (K)

2 TOPICS Optimum Anticoagulation in ACS patients : Summary from Guidelines Role of Enoxaparin in ACS Spectrum : Summary from Studies Optimizing Risk-Benefit Ratio : Highlights of Important Findings

3 Anticoagulant in STEMI : 2013 AHA and 2017 ESC Guideline SAID.ENO

4 Anticoagulant Therapy to Support Primary PCI: Recommendations JACC.2013;61(4):e

5 Periprocedural and post-procedural antithrombotic therapy in patients undergoing primary percutaneous coronary intervention Eur Heart J.2017;DOI: /eurheartj/ehx393

6 The difference between 2013 ACCF/AHA guideline and 2017 ESC (enoxaparin on PCI) Main Consideration Additional Consideration ACCF/AHA ATOLL Study - The primary composite endpoint did not differ significantly to UFH - Secondary end points were not discussed ESC ATOLL Study - (idem) - Secondary end points showed benefit of enoxaparin - No indication of increased bleeding from use of enoxaparin over UFH. - In the per protocol analysis, i.v enoxaparin was superior vs UFH in reducing the primary end points. N/A A meta-analysis of 23 PCI trials (30,966 patients, 33% primary PCI), enoxaparin was associated with a significant reduction in death compared to UFH. Primary end-points: 30-day death, complication of myocardial infarction, procedural failure and major bleeding Secondary end-points: death, recurrent myocardial infarction or ACS or urgent revascularization ACCF/AHA : American College of Cardiology/American Heart Association; ESC : European Society of Cardiology; UFH : unfractionated heparin, PCI : percutaneous coronary intervention

7 Adjunctive Anticoagulant Therapy to Support PCI After Fibrinolytic Therapy Class of Recommendatio n Level of Evidence O Gara PT, Kushner FG, Ascheim DD, et al. JACC.2013;61(4):e78-140

8 Anticoagulant in Non- STEMI : 2014 AHA and 2015 ESC Guideline

9 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes Summary of Recommendations for Initial Anticoagulant Therapy in Patients With Definite or Likely NSTE-ACS and PCI Circulation.2014;130:e

10 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes Circulation.2014;130:e

11 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes Circulation.2014;130:e

12 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes Anticoagulant Therapy in Patients Undergoing PCI: Recommendations Class I An anticoagulant should be administered to patients with NSTE-ACS undergoing PCI to reduce the risk of intracoronary and catheter thrombus formation. Intravenous UFH is useful in patients with NSTEACS undergoing PCI. Bivalirudin is useful as an anticoagulant with or without prior treatment with UFH in patients with NSTE-ACS undergoing PCI An additional dose of 0.3 mg/kg IV enoxaparin should be administered at the time of PCI to patients with NSTE-ACS who have received fewer than 2 therapeutic subcutaneous doses (eg, 1 mg/kg SC) or received the last subcutaneous enoxaparin dose 8 to 12 hours before PCI If PCI is performed while the patient is on fondaparinux, an additional 85 IU/kg of UFH should be given intravenously immediately before PCI because of the risk of catheter thrombosis LOE C C B B B Circulation.2014;130:e

13 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes Anticoagulant Therapy in Patients Undergoing PCI: Recommendations Class I (Cont d) In patients with NSTE-ACS, anticoagulant therapy should be discontinued after PCI unless there is a compelling reason to continue such therapy. Class IIa In patients with NSTE-ACS undergoing PCI who are at high risk of bleeding, it is reasonable to use bivalirudin monotherapy in preference to the combination of UFH and a GP IIb/IIIa receptor antagonist Class IIb Performance of PCI with enoxaparin may be reasonable in patients treated with upstream subcutaneous enoxaparin for NSTE-ACS Class III (Harm) Fondaparinux should not be used as the sole anticoagulant to support PCI in patients with NSTEACS due to an increased risk of catheter thrombosis LOE C B B B B Circulation.2014;130:e

14 Anticoagulant Therapy in Patients Undergoing PCI: Recommendations Class I Parenteral anticoagulation is recommended at the time of diagnosis according to both ischaemic and bleeding risks. Fondaparinux (2.5 mg s.c. daily) is recommended as having the most favourable efficacy safety profile regardless of the management strategy. LOE B B UFH if concomitant with GPIIb/IIIa inhibitors) is recommended in patients undergoing PCI B who did not receive any anticoagulant. Based on If the initial anticoagulant is fondaparinux, a single bolus of UFH should be added at the OASIS-5 B time of PCI. Enoxaparin (1 mg/kg twice daily) is recommended when fondaparinux is not available. B Eur Heart J.2015;doi: /eurheartj/ehv320

15 Anticoagulant Therapy in Patients Undergoing PCI: Recommendations Class IIa Enoxaparin should be considered as an anticoagulant for PCI in patients pretreated with s.c. enoxaparin. Class III (Harm) Crossover of heparins (UFH and LMWH) is not recommended. LOE B B Eur Heart J.2015;doi: /eurheartj/ehv320

16 VBWG OASIS-5: Study design Patients with NSTE ACS, chest discomfort <24 hours, 2: Age >60 y, ST segment, cardiac biomarkers Fondaparinux 2.5 mg sc qd Randomize N = 20,078 Outcomes ASA, clopidogrel, GP IIb/IIIa, planned cath/pci per local practice Enoxaparin 1 mg/kg sc bid Primary: Efficacy Death, MI, refractory ischemia at 9 d Safety Major bleeding at 9 d Benefit/risk Death, MI, refractory ischemia, major bleeding at 9 d Secondary: Primary outcomes plus each component at 30 d and 6 mo MICHELANGELO OASIS 5 Steering Committee. Am Heart J. 2005;150:

17 Subject Flow & Concomitant Drugs OASIS 5 Study-Drug Administration in PCI patients OASIS 5 : Fondaparinux Enoxaparin +/- Additional fondaparinux Fondaparinux No additional anticoagulan UFH Crossover of heparins (UFH and LMWH) is not recommended ESC Guideline; class IIIb *GP IIb/IIIa inhibitor may or may not be given Yusuf S, et al.n Eng J Med.2006;354.

18 VBWG OASIS-5: Treatment effect on primary efficacy outcome at 9 days Death, MI, refractory ischemia Cumulative event rate HR 1.01 ( ) Fondaparinux Enoxaparin Time (days) OASIS-5 Investigators. N Engl J Med. 2006;354:

19 Event Rate (%) Clinical Events after PCI: Day 30 P= P= P= P< Death MI Major Bleeds Death, MI,Stroke or Major Bleed 9.5 Enox (n=3089) Fonda (n=3118)

20 OASIS-5: Death, MI, refractory ischemia at 6 months VBWG HR 0.93 ( ) P = 0.06 Enoxaparin Fondaparinux Cumulative event rate Time (days) OASIS-5 Investigators. N Engl J Med. 2006;354:

21 VBWG OASIS-5: Net clinical benefit at 6 months Death, MI, refractory ischemia, major bleeding HR 0.86 ( ) P < Enoxaparin Fondaparinux Cumulative event rate Time (days) OASIS-5 Investigators. N Engl J Med. 2006;354:

22 ACS Spectrum Acute Coronary Syndrome STEMI NSTEMI / UA PCI Thrombolysis

23 Summary of Evidence Study Subjects N Dose of Enox Efficacy Safety (enox vs UFH) ATOLL 1 STEMI (primary PCI) ExTRACT-TIMI STEMI 25 2 (Thrombolysis) SYNERGY 3 NSTEMI (PCI) TIMI 11b NSTEMI 3,910 + ESSENCE 4 3, mg/kg IV (additional 0.25 mg/kg, if needed) 20, mg IV > 1.0 mg/kg SC q12h 75 yo : 0.75 mg/kg q12h Similar primary endpoint 41% RRR in the rate of the main secondary endpoint Reduced death, complication of myocardial infarction, or major bleeding 17% RRR in the primary endpoint 33% RRR in non-fatal re-infarction Reduced in the composite of death, nonfatal reinfarction, or nonfatal intracranial hemorrhage (10.1 vs 12.2%,p<0.001) Similar rate of major and minor bleeding Higher rate of major bleeding (2.1 vs 1.4%; p<0.001) Similar rate of intracranial hemorrhage 10,027 1 mg/kg q12h SC Similar primary endpoint Higher rate of TIMI major bleeding (9.1 vs 7.6%; p=0.008) Non-significant GUSTO severe bleeding 1 mg/kg q12h SC 20% RRR in the composite triple end point (death, MI or recurrent Angina) At 1 yr FU, 13% RRR in the composite triple end point Similar rate of major bleeding Higher minor bleeding 1. Montalescot G, et al.lancet.2011;378: ; 2. Antman EM, et al.n Eng J Med.2006;354: SYNERGY Trial Investigators.JAMA.2004;292: Antmant EM, et al.circulation.1999;

24 ESC, Stockholm - August 30, 2010 Hotline session ATOLL An international randomized study comparing IV enoxaparin to IV UFH in primary PCI G. Montalescot, M. Cohen, P. Goldstein, K. Huber, C. Pollack, U. Zeymer, E. Vicaut for the ATOLL investigators ATOLL: Acute STEMI Treated with primary PCI and intravenous enoxaparin Or UFH to Lower ischemic and bleeding events at short- and Long-term follow-up (Investigator-driven study) G. MONTALESCOT, DISCLOSURE: Research Grants (to the Institution) from Abbott Vascular, Bristol Myers Squibb, Boston Scientific, Centocor, Cordis, Eli-Lilly, Fédération Française de Cardiologie, Fondation de France, Guerbet Medical, INSERM, Medtronic, Pfizer, Sanofi-Aventis Group, Société Française de Cardiologie; Consulting or Lecture Fees from Accumetrics, Astra-Zeneca, Bayer, Biotronik, Boehringer-Ingelheim, Bristol- Myers Squibb, Daichi-Sankyo, Eisai, Eli-Lilly, Menarini, MSD, Novartis, Portola, Sanofi-Aventis Group, Schering- Plough, Servier and The Medicines Company.

25 ATOLL Trial design Randomization as early as possible (MICU +++) Real life population (shock, cardiac arrest included) No anticoagulation and no lytic before Rx Similar antiplatelet therapy in both groups MICU: Mobile Intensive Care Unit IVRS: Interactive Voice Response System STEMI Primary PCI ENOXAPARIN IV 0.5 mg/kg (n=450) with or without GPIIbIIIa ENOXAPARIN SC IVRS Primary PCI UFH IV (n=460) IU with GP IIbIIIa IU without GP IIbIIIa (Dose ACT-adjusted) UFH IV or SC 30 days 1 EP: Death, Complication of MI, Procedure Failure, Major Bleeding Main 2 EP: Death, recurrent MI / ACS, Urgent Revascularization

26 % of patients Primary Endpoint Death, Complication of MI, Procedure Failure or Major Bleeding RRR = 17% P = UFH ENOX RRR: Relative Risk Reduction

27 % of patients Death, Complication of MI or Major bleeding 16 Net clinical benefit RRR = 32% P = ,2 UFH ENOX 4 2 0

28 % of patients All Safety Endpoints P = NS for all NS: Non Significant Protocole definitions (STEEPLE)

29 A Direct Comparison of Intravenous Enoxaparin With Unfractionated Heparin in Primary Percutaneous Coronary Intervention (from the ATOLL Trial) - Collet JP, Huber K, Cohen M, et al.am J Cardiol.2013;112: Result of the pre-specified per-protocol analysis Pre-randomization anticoagulation was not permitted in ATOLL. Later crossover, however, did occur in a small group of patients that was removed from the study population of this per-protocol analysis. Primary end point : all-cause mortality, complication of myocardial infarction, procedural failure, or major bleeding. Secondary end point : all-cause mortality, recurrent acute coronary syndrome, or urgent revascularization Baseline and Procedural characteristics were well balanced between the 2 treatment groups Of 910 randomized patients, 795 patients (87.4%) are included in this per protocol analysis

30 A Direct Comparison of Intravenous Enoxaparin With Unfractionated Heparin in Primary Percutaneous Coronary Intervention (from the ATOLL Trial) - Collet JP, Huber K, Cohen M, et al.am J Cardiol.2013;112: Result of the prespecified per-protocol analysis Enoxaparin reduced significantly the rates of the primary end point by 23% (p=0.012) and secondary end point by 63% (p<0.0001) Enoxaparin resulted in less major bleeding (RR 0.46; p=0.050) Enoxaparin resulted in significant improvement of the NET CLINICAL BENEFIT (RR 0.46; p=0.0002) All cause mortality was also reduced by enoxaparin by 64% (p=0.003)

31 A Direct Comparison of Intravenous Enoxaparin With Unfractionated Heparin in Primary Percutaneous Coronary Intervention (from the ATOLL Trial) - Collet JP, Huber K, Cohen M, et al.am J Cardiol.2013;112: CONCLUSION : In the per protocol analysis of the ATOLL trial, pertinent to >87% of the study population, enoxaparin was superior to UFH in reducing ischemic end points and mortality. The present per protocol analysis of the ATOLL trial confirms further these data when the drug is properly used without switching with UFH.

32 Protocol Design STEMI < 6 h Lytic eligible ASA Lytic choice by MD (TNK, tpa, rpa, SK) Double-blind, double-dummy ENOX < 75 y: 30 mg IV bolus SC 1.0 mg / kg q 12 h (Hosp DC) 75 y: No bolus SC 0.75 mg / kg q 12 h (Hosp DC) CrCl < 30: 1.0 mg / kg q 24 h UFH 60 U / kg bolus (4000 U) Inf 12 U / kg / h (1000 U / h) Duration: at least 48 h Cont d at MD discretion Day 30 1 Efficacy Endpoint: Death or Nonfatal MI 1 Safety Endpoint: TIMI Major Hemorrhage

33 Main Results Primary Endpoint: Death or non-fatal re-mi by 30 days UFH ENOX Main Secondary Endpoint: Death, non-fatal re-mi, urgent revascularization by 30 days UFH ENOX % RR = 0.83 p = % RR = 0.81 p = Days Days 33% RRR in remi by 48 h (P=0.002) 19% RRR in Death/MI by 72 h (P<0.001) 12% RRR in by 48 h (P=0.02) N Engl J Med 2006;354:

34 % Events TIMI major bleeding Stratified by age Unfractionated heparin ARD 0.8% RR 1.67 ( ) p=< < 75 years n = 17, Enoxaparin ARD 0.4% RR 1.15 ( ) p= years n = 2513 ARD: Absolute Risk Difference RR: Relative Risk

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36 The SYNERGY trial Superior Yield of the New strategy of Enoxaparin, Revascularization & GlYcoprotein IIb/IIIa Inhibitors

37 Study Design 1 mg/kg SC Q12H Enoxaparin High-Risk ACS Patients Randomize (n = 8,000) IV Heparin At least 2 of 3 required: Age 60 ST (transient) or (+) CK-MB or Troponin 60 U/kg 12 U/kg/hr (aptt sec) Early invasive strategy Other therapy per AHA/ACC Guidelines (ASA, -blocker, ACE, clopidogrel, GP IIb/IIIa) Primary endpoint: Death or MI at 30 days 1

38 Primary Results (30 Days) Enoxaparin UFH Unadjusted (n = 4993) (n = 4985) P-value Death and MI (%) Death (%) MI (%)

39 Bleeding Events Enoxaparin UFH (n = 4993) (n = 4985) P-value GUSTO severe TIMI major - clinical: CABG-related Non-CABG-related H/H drop - algorithm Any RBC transfusion ICH < 0.1 < 0.1 NS Overall, it appears that changing antithrombin therapy during the treatment course is not associated with any treatment benefit and is associated with an INCREASED risk of bleeding 1

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42 Cumulative Event Rate (%) ESSENCE Death, MI, or recurrent angina at 1-year follow-up 40 P = UFH Enoxaparin Months Source: Goodman SG, et al. J Am Coll Cardiol. 2000;36:693.

43 ESSENCE Efficacy results at 1-year follow-up UFH Enoxaparin Absolute difference Relative difference* P Triple endpoint % 30 days year Double endpoint 30 days year * Hazard ratio or odds ratio. Source: Goodman SG, et al. J Am Coll Cardiol. 2000;36:693.

44 TIMI 11B Enoxaparin 30 mg IV bolus/ 1 mg/kg SC, q12h Enoxaparin 40 or 60 mg SC, q12h (40 mg if pt < 65kg) Pt. With UA/NQMI 24h Acute = Day 8 Chronic = Day 43 Death, nonfatal MI Urgent revascularization UFH IV bolus/infusion 72h Placebo SC, q12h Source: Antman EM, et al. Circulation. 1999;100:1593.

45 Percentage of Patients TIMI 11B Death, MI, urgent revascularization: early Rx phase UFH Hours from Randomization Enoxaparin RRR 23.8% P = Source: Antman EM, et al. Circulation. 1999;100:1593.

46 Percentage of Patients TIMI 11B Death, MI, urgent revascularization at Day Enoxaparin UFH Days Source: Antman EM, et al. Circulation. 1999;100:1593.

47 Percentage of Patients TIMI 11B Death, MI, urgent revascularization at Day UFH Enoxaparin RRR = 12.3% P = Days Source: Antman EM, et al. Circulation. 1999;100:1593.

48 TIMI 11B Major hemorrhage UFH Enoxaparin (n = 1,936) (n = 1,938) P 72 hours 0.7% 0.8% NS Hospital phase 1.0% 1.5% NS Placebo Enoxaparin (n = 1,185) (n = 1,179) P Outpatient phase 1.5% 2.9% Source: Antman EM, et al. Circulation. 1999;100:1593.

49 Percentage of patients TIMI 11B-ESSENCE meta-analysis 1-year follow-up D/MI/urg revasc UFH 25.8% HR Death 0.90 (0.75,1.08) ENOX 23.3% P = Log rank MI 0.91 (0.77,1.07) Urg revasc 0.86 (0.76,0.97) Months D/MI/UR B 0.88 (0.80,0.97) Hazard ratio Antman EM, et al. Eur Heart J. 2002;23:308.

50 # UTVR: Urgent Target-Vessel Revascularization #

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53 Enoxaparin in Patients with Renal Impairment Sub analysis from STEEPLE trial Major bleeding occurred more often in patients with renal impairment compared with those without (2.7% vs 1.5%, P =.04). Enoxaparin was associated with less major bleeding than UFH with normal renal function (0.9% for enoxaparin 0.5 mg/kg or 1.0% for enoxaparin 0.75 mg/kg vs 2.6%, respectively; both P =.01 vs UFH), a trend toward less major bleeding with impaired renal function (2.6% or 1.8% vs 3.8%, P =.18 for enoxaparin 0.5 mg/kg and P =.47 for 0.75 mg/kg vs UFH) The incidence of death, nonfatal myocardial infarction, or urgent target-vessel revascularization was similar between patients with and without renal impairment White HD, et al.am Heart J.2009;157:

54 Enoxaparin in Obese Patients Sub analysis from SYNERGY trial Thirty-two percent of patients were obese (BMI 30) Obese patients were more likely to be underdosed than non-obese patients. After adjustment, increased BMI was not an independent predictor of bleeding outcomes or 30-day death/myocardial infarction, but increased BMI was predictive of lower 1-year mortality in the subgroup of patients with BMI at baseline below approximately 30 kg/m 2 Standard dosing of enoxaparin should be used in patients without extreme obesity due to limited outcome data in these patients. Mahaffey KW, et al.international Journal of Cardiology.2010;139(2):

55 Enoxaparin in Elderly Patients Sub analysis from SYNERGY trial 25.5% (2540) of study population were 75 years of age. After adjustment, advanced age (per 10 years) was associated with 30-day death or MI [risk odds ratios [ROR] : 1.14, P = 0.002], 30-day death (ROR: 1.54, P < ), and 1-year death (ROR: 1.47, P < ), as well with TIMI major bleeding (ROR: 1.21, P = 0.001), GUSTO severe bleeding (ROR: 1.20, P = 0.047), and transfusion (ROR: 1.04, P = 0.324). Although higher rates of adverse events are seen in the oldest subgroup (age 75 years) treated with enoxaparin, statistical comparisons confirm similar efficacy and safety of enoxaparin and UFH across age subgroups as was demonstrated overall in SYNERGY. Mahaffey KW, et al.international Journal of Cardiology.2010;139(2):

56 Systematic Review & Metaanalysis Low-molecular-weight heparins vs. unfractionated heparin in the setting of percutaneous coronary intervention for STelevation myocardial infarction: a meta-analysis -- J Thromb Haemost.2011;9: Efficacy and safety of enoxaparin versus unfractionated heparin during percutaneous coronary intervention: systematic review and meta-analysis BMJ 2012;344:e553 Comparison of bleeding complications and 3-year survival with low-molecular-weight heparin versus unfractionated heparin for acute myocardial infarction: The FAST-MI registry Archives of Cardiovascular Disease.2012;105:347-54

57 Low-molecular-weight heparins vs. unfractionated heparin in the setting of percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis Navarese EP, De Luca G, Castriota F, et al. J Thromb Haemost.2011;9: studies (n=16,286) Individual and summary relative risk for mortality in patients treated with LMWHs vs UFH

58 Low-molecular-weight heparins vs. unfractionated heparin in the setting of percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis Navarese EP, De Luca G, Castriota F, et al. J Thromb Haemost.2011;9: studies (n=16,286) Individual and summary adjusted relative risk for mortality in patients treated with LMWHs vs UFH LMWH were associated with greater efficacy and safety than UFH in STEMI patients treated with PCI.

59 Low-molecular-weight heparins vs. unfractionated heparin in the setting of percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis Navarese EP, De Luca G, Castriota F, et al. J Thromb Haemost.2011;9: studies (n=16,286) LMWH treatment was associated with a significant reduction in the rate of major bleeding complications in the PCI group Individual and summary relative risk for major bleeding in patients treated with LMWHs vs UFH

60 Low-molecular-weight heparins vs. unfractionated heparin in the setting of percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis Navarese EP, De Luca G, Castriota F, et al. J Thromb Haemost.2011;9: Theoretically explanation for LMWH greater efficacy : LMWHs have a four-fold greater activity against activated factor X LMWHs : much more predictable anticoagulant response than UFH as they do not bind to plasma proteins Pleiotropic effects such as blunting the increase in von-willebrand factor and a relative lack of associated platelet activation might influence its antithrombotic properties in addition to superior anticoagulant effects

61 Efficacy and safety of enoxaparin versus unfractionated heparin during percutaneous coronary intervention: systematic review and meta-analysis Silvain J, Beygui F, Pollack C, et al.bmj.2012;344:e studies (n=30,966)

62 Efficacy and safety of enoxaparin versus unfractionated heparin during percutaneous coronary intervention: systematic review and meta-analysis Silvain J, Beygui F, Pollack C, et al.bmj.2012;344:e studies (n=30,966)

63 Efficacy and safety of enoxaparin versus unfractionated heparin during percutaneous coronary intervention: systematic review and meta-analysis Silvain J, Beygui F, Pollack C, et al.bmj.2012;344:e studies (n=30,966)

64 Efficacy and safety of enoxaparin versus unfractionated heparin during percutaneous coronary intervention: systematic review and meta-analysis Silvain J, Beygui F, Pollack C, et al.bmj.2012;344:e studies (n=30,966)

65 Efficacy and safety of enoxaparin versus unfractionated heparin during percutaneous coronary intervention: systematic review and meta-analysis Silvain J, Beygui F, Pollack C, et al.bmj.2012;344:e553 CONCLUSION : During percutaneous coronary intervention, enoxaparin seems to be superior to UFH in reducing all cause mortality and ischaemic and bleeding end points. This superiority was particularly evident in patients with STEMI undergoing primary PCI

66 Efficacy and safety of enoxaparin versus unfractionated heparin during percutaneous coronary intervention: systematic review and meta-analysis Silvain J, Beygui F, Pollack C, et al.bmj.2012;344:e553

67 Comparison of bleeding complications and 3-year survival with low-molecular-weight heparin versus unfractionated heparin for acute myocardial infarction: The FAST-MI registry Puymirat E, Aissaoui N, Silvain J, et al.archives of Cardiovascular Disease.2012;105: Nation-wide registry study (real-world experience) included consecutive AMI patients admitted to an intensive care unit less than 48 hours from symptom onset in 223 participating centres in France (n=2,854)

68 Comparison of bleeding complications and 3-year survival with low-molecular-weight heparin versus unfractionated heparin for acute myocardial infarction: The FAST-MI registry Puymirat E, Aissaoui N, Silvain J, et al.archives of Cardiovascular Disease.2012;105: Nation-wide registry study (real-world experience) included consecutive AMI patients admitted to an intensive care unit less than 48 hours from symptom onset in 223 participating centres in France (n=2,854) CONCLUSION : LMWH in real-world clinical practice is associated with less bleeding and a better 3-year survival rate in patients with AMI.

69 CONCLUSION High-risk ACS patients needs revascularization treatment with PCI as one of the main choice Optimum anticoagulation is one of key treatment success How we choose anticoagulant agents is based on the risk of thrombosis and bleeding Enoxaparin has been studied extensively across ACS spectrum and has benefit over UFH.