Avoiding Intelligence Failures in the Cardiac Catheterization Laboratory: Strategies for the Safe and Rational Use of Dalteparin or Enoxaparin during Percutaneous Coronary Intervention

摘要: Low-molecular-weight heparin (LMWH) has been a mainstay for the management of acute coronary syndromes (ACS) almost decade. However, several recent developments have seriously threatened prominence this drug class: (i) adoption an early invasive strategy, frequently leading to percutaneous intervention (PCI) where dosing and monitoring LMWH is unfamiliar most operators, (ii) results SYNERGY trial, which not only failed establish superiority enoxaparin over unfractionated with respect efficacy, but also demonstrated more bleeding LMWH, (iii) REPLACE-2 ACUITY trials, advantages ACS PCI treatment strategy based on direct thrombin inhibition bivalirudin. To confront these challenges, cardiologists committed continued use must develop safe user-friendly approaches transition patients from noninvasive settings. This review summarizes approach that takes advantage fact can be readily monitored point-of-care activated clotting time (ACT) assay. assay inexpensive, available in virtually every catheterization laboratory, familiar operators who monitor (UFH). A key concept presented ACT accurate measure LMWH-induced anticoagulation than UFH-induced anticoagulation. Our preliminary work suggests during should target 175 seconds presence, 200 absence, adjunctive glycoprotein IIb/IIIa inhibition. Sheath removal recommended at < 160. These guidelines may facilitate potential reduce cost (less expensive bivalirudin), diminish need intravenous medication (can administered subcutaneously setting minimal no monitoring), provide ideal anticoagulant (easy ACT, least partially reversible protamine event perforation, effective antithrombin platelet activation, thereby potentially reducing routine inhibition).