PMID- 19966370
OWN - NLM
STAT- MEDLINE
DCOM- 20100311
LR  - 20220318
IS  - 1557-2501 (Electronic)
IS  - 1042-3931 (Linking)
VI  - 21
IP  - 12
DP  - 2009 Dec
TI  - Avoiding intelligence failures in the cardiac catheterization laboratory: 
      Strategies for the safe and rational use of dalteparin or enoxaparin during 
      percutaneous coronary intervention.
PG  - 653-64
AB  - Low-molecular-weight heparin (LMWH) has been a mainstay for the management of 
      acute coronary syndromes (ACS) for almost a decade. However, several recent 
      developments have seriously threatened the prominence of this drug class: (i) the 
      adoption of an early invasive strategy, frequently leading to percutaneous 
      coronary intervention (PCI) where the dosing and monitoring of LMWH is unfamiliar 
      to most operators, (ii) the results of the SYNERGY trial, which not only failed 
      to establish the superiority of enoxaparin over unfractionated heparin with 
      respect to efficacy, but also demonstrated more bleeding with LMWH, and (iii) the 
      results of the REPLACE-2 and ACUITY trials, which have demonstrated the 
      advantages of an ACS and PCI treatment strategy based on direct thrombin 
      inhibition with bivalirudin. To confront these challenges, cardiologists 
      committed to the continued use of LMWH must develop safe and user-friendly 
      approaches to transition patients from the noninvasive to invasive settings. This 
      review summarizes an approach that takes advantage of the fact that LMWH can be 
      readily monitored with the point-of-care activated clotting time (ACT) assay. 
      This assay is inexpensive, available in virtually every catheterization 
      laboratory, and familiar to most operators who monitor unfractionated heparin 
      (UFH). A key concept that is presented is that the ACT is a more accurate measure 
      of LMWH-induced anticoagulation than of UFH-induced anticoagulation. Our 
      preliminary work suggests that during PCI operators should target an ACT of 175 
      seconds in the presence, and 200 seconds in the absence, of adjunctive 
      glycoprotein IIb/IIIa inhibition. Sheath removal is recommended at an ACT < 160. 
      These guidelines may facilitate continued use of LMWH, which has the potential to 
      reduce cost (less expensive than bivalirudin), diminish the need for intravenous 
      medication (can be administered subcutaneously in the noninvasive setting with 
      minimal to no monitoring), and provide an ideal anticoagulant during PCI (easy to 
      monitor with the ACT, at least partially reversible with protamine in the event 
      of coronary perforation, effective antithrombin with no platelet activation, 
      thereby potentially reducing the need for routine adjunctive IIb/IIIa 
      inhibition).
FAU - Marmur, Jonathan D
AU  - Marmur JD
AD  - Department of Medicine, State University of New York Health Science Center at 
      Brooklyn, 11203-2098, USA. jonathan@marmur.com
FAU - Bullock-Palmer, Renee P
AU  - Bullock-Palmer RP
FAU - Poludasu, Shyam
AU  - Poludasu S
FAU - Cavusoglu, Erdal
AU  - Cavusoglu E
LA  - eng
PT  - Journal Article
PT  - Review
PL  - United States
TA  - J Invasive Cardiol
JT  - The Journal of invasive cardiology
JID - 8917477
RN  - 0 (Anticoagulants)
RN  - 0 (Enoxaparin)
RN  - S79O08V79F (Dalteparin)
SB  - IM
MH  - Angioplasty, Balloon, Coronary/adverse effects/*methods
MH  - Anticoagulants/adverse effects/therapeutic use
MH  - Cardiac Catheterization/adverse effects/methods
MH  - Coronary Artery Disease/therapy
MH  - Dalteparin/*therapeutic use
MH  - Enoxaparin/adverse effects/*therapeutic use
MH  - Humans
MH  - Whole Blood Coagulation Time
RF  - 76
EDAT- 2009/12/08 06:00
MHDA- 2010/03/12 06:00
CRDT- 2009/12/08 06:00
PHST- 2009/12/08 06:00 [entrez]
PHST- 2009/12/08 06:00 [pubmed]
PHST- 2010/03/12 06:00 [medline]
PST - ppublish
SO  - J Invasive Cardiol. 2009 Dec;21(12):653-64.