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© The European Society of Cardiology 2007. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Antithrombin treatment in patients with non-ST-elevation acute coronary syndromes undergoing percutaneous coronary intervention

Jean-Philippe Collet1,2, Raphaëlle Dumaine1,2 and Gilles Montalescot1,2,*

1 Institut de Cardiologie, Pitié-Salpêtrière University Hospital, Bureau 2-236, 47 Boulevard de l'Hopital, 75013 Paris, France
2 Institut de Cardiologie (APHP) and INSERM unit#856, Pitié-Salpêtriére University Hospital, 47 Boulevard de l'Hopital, 75013 Paris, France

* Corresponding author. Tel: +33 1 42 16 30 07; fax: +33 1 42 16 29 31. E-mail address: gilles.montalescot{at}psl.aphp.fr

Unfractionated heparin (UFH) has long been the only thrombin inhibitor used in non ST-elevation ACS (NSTE-ACS) patients undergoing percutaneous coronary intervention. Better anticoagulation regimens have been developed given the limitations of UFH which include its sometimes difficult-to-manage effects on coagulation, the need for repeated monitoring of coagulation, the narrow therapeutic window, the potential induction of platelet activation, and the risk of thrombocytopenia. The three new anticoagulants, enoxaparin, fondaparinux, and bivalirudin have demonstrated improvements, against UFH and represent new alternative therapies. We have reviewed the major challenges for each of them to become ideal. Additional data are needed for enoxaparin when accumulation of the drug is likely to occur (obese patients, renal insufficiency) given the risk of subsequent bleeding. Fondaparinux and bivalirudin represent an opportunity to improve safety. However, cost is a real concern for bivalirudin especially when access to the catheterization laboratory is delayed. In addition, whether bivalirudin can replace selective procedural abciximab use in the catheterization laboratory in high-risk ACS patients also remains to be established. Catheter thrombosis is a concern for fondaparinux and the need for combining UFH with fondaparinux to overcome this potential detrimental side effect is an unexpected limitation that needs re-appraisal.

Key Words: Unfractionated heparin • Direct thrombin inhibitor • Low molecular weight heparin • Acute coronary syndrome • Percutaneous coronary intervention


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