PMID- 18577763
OWN - NLM
STAT- MEDLINE
DCOM- 20080925
LR  - 20220310
IS  - 1542-6270 (Electronic)
IS  - 1060-0280 (Linking)
VI  - 42
IP  - 7
DP  - 2008 Jul
TI  - 2007 Guideline update for unstable angina/non-ST-segment elevation myocardial 
      infarction: focus on antiplatelet and anticoagulant therapies.
PG  - 989-1001
LID - 10.1345/aph.1L063 [doi]
AB  - OBJECTIVE: To summarize key changes in the 2007 American College of 
      Cardiology/American Heart Association (ACC/AHA) guideline recommendations for 
      pharmacologic therapy as they relate to antiplatelets and anticoagulants, and to 
      evaluate the evidence from several landmark trials that was used to support the 
      guideline updates for these agents. DATA SOURCES: Literature was accessed through 
      MEDLINE (1950-January 2008) using the search terms acute coronary syndromes, 
      unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), 
      antiplatelet, and anticoagulant. All papers were cross-referenced to identify 
      additional studies. STUDY SELECTION AND DATA EXTRACTION: ACC/AHA guidelines, 
      relevant original research articles, and review articles were evaluated. Studies 
      with more than 1000 patients were the focus of the review. DATA SYNTHESIS: UA and 
      NSTEMI are the most common presentations of acute coronary syndrome. The recently 
      updated ACC/AHA guidelines for management of this condition were based on 
      significant advances in pharmacotherapy including expanded use of drug-eluting 
      stents, pretreatment with clopidogrel, and newer anticoagulants such as 
      bivalirudin and fondaparinux. Landmark trials have been published that describe 
      advances in the use of antiplatelets and anticoagulants. According to the 
      guidelines, unfractionated heparin (UFH) and enoxaparin are preferred options for 
      both invasive and conservative management. Enoxaparin was noninferior to UFH for 
      invasive management in the SYNERGY trial, although it was associated with a 
      higher incidence of bleeding. Other alternatives for an invasive strategy per the 
      guidelines include bivalirudin and fondaparinux. Bivalirudin (alone or with 
      glycoprotein [GP] IIb/IIIa inhibitor) was compared with heparin plus GP IIb/IIIa 
      inhibitor in the ACUITY trial of patients undergoing early invasive management. 
      The bivalirudin groups were noninferior to standard of care, although bivalirudin 
      alone was associated with less bleeding. Fondaparinux was found to be noninferior 
      to enoxaparin and was associated with fewer bleeding events in the OASIS-5 study 
      of patients who were not treated with an early invasive approach. Accordingly, 
      the guidelines 1list fondaparinux as an alternative for a conservative strategy 
      or in patients at increased risk of bleeding. CONCLUSIONS: Clinicians should be 
      familiar with the updated 2007 ACC/AHA guidelines and the clinical trial evidence 
      that serves as the basis for these recommendations. It is paramount for 
      institutions to outline a preferred and consistent treatment approach. These 
      decisions should involve a review of established efficacy, bleeding risk, need 
      for anticoagulant reversal, costs, and clinician familiarity with different 
      treatment regimens.
FAU - Coons, James C
AU  - Coons JC
AD  - Department of Pharmacy, Allegheny General Hospital, Pittsburgh, PA 15212, USA. 
      jcoons@wpahs.org
FAU - Battistone, Sarah
AU  - Battistone S
LA  - eng
PT  - Journal Article
DEP - 20080624
PL  - United States
TA  - Ann Pharmacother
JT  - The Annals of pharmacotherapy
JID - 9203131
RN  - 0 (Anticoagulants)
RN  - 0 (Enoxaparin)
RN  - 0 (Hirudins)
RN  - 0 (Peptide Fragments)
RN  - 0 (Platelet Aggregation Inhibitors)
RN  - 0 (Platelet Glycoprotein GPIIb-IIIa Complex)
RN  - 0 (Polysaccharides)
RN  - 0 (Recombinant Proteins)
RN  - 9005-49-6 (Heparin)
RN  - A74586SNO7 (Clopidogrel)
RN  - J177FOW5JL (Fondaparinux)
RN  - OM90ZUW7M1 (Ticlopidine)
RN  - TN9BEX005G (bivalirudin)
SB  - IM
MH  - American Heart Association
MH  - Angina, Unstable/*drug therapy
MH  - Anticoagulants/*therapeutic use
MH  - Clopidogrel
MH  - Drug-Eluting Stents
MH  - Enoxaparin/therapeutic use
MH  - Fondaparinux
MH  - Heparin/therapeutic use
MH  - Hirudins
MH  - Humans
MH  - Myocardial Infarction/*drug therapy
MH  - Peptide Fragments/therapeutic use
MH  - Platelet Aggregation Inhibitors/*therapeutic use
MH  - Platelet Glycoprotein GPIIb-IIIa Complex/antagonists & inhibitors
MH  - Polysaccharides/therapeutic use
MH  - Practice Guidelines as Topic
MH  - Recombinant Proteins/therapeutic use
MH  - Ticlopidine/analogs & derivatives/therapeutic use
MH  - United States
EDAT- 2008/06/26 09:00
MHDA- 2008/09/26 09:00
CRDT- 2008/06/26 09:00
PHST- 2008/06/26 09:00 [pubmed]
PHST- 2008/09/26 09:00 [medline]
PHST- 2008/06/26 09:00 [entrez]
AID - aph.1L063 [pii]
AID - 10.1345/aph.1L063 [doi]
PST - ppublish
SO  - Ann Pharmacother. 2008 Jul;42(7):989-1001. doi: 10.1345/aph.1L063. Epub 2008 Jun 
      24.