Gabriel Ruvin S, White Harvey D
Green Lane Cardiovascular Service, Auckland City Hospital, Level 3, Building 32, Private Bag 92 024, Auckland 1030, New Zealand.
Expert Rev Cardiovasc Ther. 2007 Sep;5(5):851-7. doi: 10.1586/14779072.5.5.851.
Pharmacologic reperfusion remains the most common treatment strategy for ST-elevation myocardial infarction (STEMI) worldwide. Unfractionated heparin (UFH) is the established adjunctive antithrombotic agent used with fibrinolytic agents. Low-molecular-weight heparins (LMWHs) are a potential alternative to UFH, but have not been evaluated in large cohorts of patients. The Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment (ExTRACT)-Thrombolysis in Myocardial Infarction (TIMI) 25 was a double-blind, double-dummy randomized controlled trial, of 20,479 patients, which demonstrated the superiority of enoxaparin over UFH in reducing death or nonfatal myocardial infarction (MI) at 30 days, with an increase in major bleeding. The composite of death, nonfatal MI and nonfatal intracranial hemorrhage, was reduced with enoxaparin. Elderly patients (> or = 75 years of age) received a novel enoxaparin dosing regimen and when compared with UFH, benefited from a lower relative bleeding risk than younger patients without compromising efficacy in preventing death or MI. Intracranial hemorrhage rates were similar. The net clinical benefit of enoxaparin over UFH was maintained regardless of whether patients were on clopidogrel or not, or whether percutaneous coronary intervention was performed. Enoxaparin is an appropriate choice for adjunctive therapy with fibrinolysis in patients with STEMI.
在全球范围内，药物再灌注仍然是ST段抬高型心肌梗死（STEMI）最常见的治疗策略。普通肝素（UFH）是与纤溶药物联用的既定辅助抗栓药物。低分子量肝素（LMWHs）是UFH的一种潜在替代药物，但尚未在大量患者队列中进行评估。急性心肌梗死治疗用依诺肝素与溶栓再灌注（ExTRACT）-心肌梗死溶栓（TIMI）25试验是一项针对20479例患者的双盲、双模拟随机对照试验，该试验表明，依诺肝素在降低30天时的死亡或非致命性心肌梗死（MI）方面优于UFH，但大出血有所增加。依诺肝素降低了死亡、非致命性MI和非致命性颅内出血的复合发生率。老年患者（≥75岁）接受了一种新的依诺肝素给药方案，与UFH相比，其相对出血风险低于年轻患者，且在预防死亡或MI方面不影响疗效。颅内出血发生率相似。无论患者是否使用氯吡格雷，或是否进行经皮冠状动脉介入治疗，依诺肝素相对于UFH的净临床获益均得以维持。依诺肝素是STEMI患者溶栓辅助治疗的合适选择。
