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Circulation.2014;130:e344-426
2014 AHA/ACC Guideline for the Management of
Patients With NonST-Elevation Acute Coronary
Syndromes
Circulation.2014;130:e344-426
2014 AHA/ACC Guideline for the Management of
Patients With NonST-Elevation Acute Coronary
Syndromes
Circulation.2014;130:e344-426
ESC guidelines 2015
(ACS NSTE)
ESC guidelines 2015
(ACS NSTE)
2011 ACC/AHA Recommendation
2015
Enoksaparin (1 mg/kg dua kali sehari) baik untuk pasien
dengan risiko perdarahan rendah
(Kelas I-B).
ENOXAPARIN in
high risk NSTE-ACS + early invasive
SYNERGY
Efficacy not superior but at least as effective as UFH
(Unfractionated Heparin) in the overall population (met
criteria for non inferiority).
Minor bleeding more frequent with enoxaparin.
ESSENCE 97 3,171
ACUTE II 02 525
INTERACT 03 746
A TO Z 04 3,620
SYNERGY 04 9,974
ALL 21,946
Enox UFH Enox UFH Enox UFH
+ + + + + +
0 10 20 0.5 1 2 1 10 102 102 10 1 0 5 10 0.1 0.5 1 2 10
Incidence (%) OR (95% CI) NNT (95% CI) Incidence (%) OR (95% CI)
UFH 10.1 vs. 11.0 0.91 (0.83 0.99) 113 (61 1,438) 3.9 vs 3.7 1.1 (0.96 1.3)
Enoxaparin
Bassand JP, et al. Eur Heart J. 28:1598-1660.
2014 AHA/ACC Guideline for the Management of
Patients With NonST-Elevation Acute Coronary
Syndromes
If the initial anticoagulant is fondaparinux, a single bolus of UFH should be added at the Based
B on
time of PCI. OASIS-5
Class IIa
EXTRACT-TIMI 25 2
Among STEMI patients undergoing PCI following fibrinolysis,
ENOXAPARIN was superior to UFH for efficacy with similar safety profile.
- significantly less death or re MI
- both delayed onset and lower incidence of PCI
- no difference in bleeding
- less stroke
Reff.
1. The ASSENT 3 Investigators. Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin:
the ASSENT 3 randomised trial. Lancet 2001;358:605-13.
2. N Engl J Med 2006;354:1477-88.
Main Results
ExTRACT TIMI 25
Primary Endpoint: Main Secondary Endpoint:
Death or non-fatal re-MI by 30 days Death, non-fatal re-MI, urgent
revascularization by 30 days
UFH UFH
12.0 14.5
9.9 11.7
ENOX ENOX
% %
RR = 0.83 RR = 0.81
p = 0.000003 p = 0.000001
Days Days
Tabel 13 :
Fibrinolytic therapy
Recommendations Class Level
Antithrombin co-therapy with fibrinolysis
Anticoagulation is recommended in STEMI patients treated with lytics until revascularization (if
performed) or for the duration of hospital stay up to 8 days. I C
The anticoagulant can be :
* Enoxaparin i.v. followed by s.c. (using the regimen described below) (preferred over UFH). I A
* UFH given as a weight-adjusted i.v. bolus & infusion. I C
In patients treated with streptokinase, fondaparinux i.v. bolus followed by s.c. dose 24 h later. IIa B
25
ESC guidelines 2012 (ACS - STEMI)
Tabel 16 :
Doses of antiplatelet & antithrombin co-therapies
Doses of antithrombin co-therapies
With primary PCI
Enoxaparin 0.5 mg/kg i.v. bolus.
With fibrinolytic therapy
In patients <75 years of age :
30 mg i.v. bolus followed 15 min later by 1 mg/kg s.c. every 12 h until hospital discharge
for a maximum of 8 days. The first two doses should not exceed 100 mg.
In patients >75 years of age :
Enoxaparin
no i.v. bolus; start with s.c. dose of 0.75 mg/kg with a maximum of 75 mg for the first
two s.c. doses.
In patients with creatinine clearance of <30 mL/min, regardles of age :
the s.c. doses are given once every 24 h.
Without reperfusion therapy
Enoxaparin Same dose as with fibrinolytic therapy.
Tabel 18 :
Initial dosing of antithrombotic agents in patients with chronic kidney disease
(estimated creatinine clearance <60 mL/min)
Recommendation
No adjusment of bolus dose. Following thrombolysis, in patients with creatinin
Enoxaparin
clearance <30 mL/min, the s.c. doses are given once every 24 h.
26
Anticoagulant Therapy to Support Primary PCI:
Recommendations
Anticoagulant in PCI
STEMI Study 0.5 mg/kg IV Similar primary endpoint Similar rate of major and
(primary PCI) ATOLL 1 (additional 0.25 minor bleeding
41% RRR in the rate of the main
mg/kg, if needed) secondary endpoint
Reduced death, complication of
myocardial infarction, or major
bleeding
STEMI ExTRAC 30 mg IV > 1.0 17% RRR in the primary endpoint Higher rate of major
(Thrombolysis) T-TIMI mg/kg SC q12h bleeding (2.1 vs 1.4%;
33% RRR in non-fatal re-infarction
25 2 p<0.001)
75 yo : 0.75 Reduced in the composite of death,
mg/kg q12h Similar rate of intracranial
nonfatal reinfarction, or nonfatal
hemorrhage
intracranial hemorrhage (10.1 vs
12.2%,0<0.001)
NSTEMI SYNERG 1 mg/kg q12h SC Similar primary endpoint Higher rate of TIMI major
(PCI) Y3 bleeding (9.1 vs 7.6%;
p=0.008)
Non-significant GUSTO
severe bleeding
NSTEMI TIMI 11b 1 mg/kg q12h SC 20% RRR in the composite triple Similar rate of major
end point (death, MI or recurrent bleeding
ESSENC Angina) Higher minor bleeding
E4 At 1 yr FU, 13% RRR in the
composite triple end point
1. Montalescot G, et al.Lancet.2011;378:693-703; 2. Antman EM, et al.N Eng J Med.2006;354:1477-88. 3. SYNERGY Trial Investigators.JAMA.
2004;292:45-54. 4. Antmant EM, et al.Circulation.1999;1602-8.
Enoxaparin in ACS STEMI and PCI
Intravenous enoxaparin vs. UFH in PCI
23%
Death or re-MI
(p<0.001)
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