Key result
Supplemental IV enoxaparin combined with SQ enoxaparin achieved therapeutic anti-Xa levels (≥0.5 U/ml) in 100% of STEMI patients undergoing primary PCI, compared to 25% with SQ enoxaparin alone.
Why the study?
Does supplemental IV enoxaparin added to subcutaneous enoxaparin achieve therapeutic anti-Xa levels in STEMI patients undergoing primary PCI?
RCT (n=33)
randomized
Does supplemental IV enoxaparin added to subcutaneous enoxaparin achieve therapeutic anti-Xa levels in STEMI patients undergoing primary PCI?
Absolute Event Rate: 100% vs 25%
A single subcutaneous dose of enoxaparin is insufficient to achieve therapeutic anti-Xa levels during primary PCI for STEMI, but supplemental IV dosing reliably achieves therapeutic anticoagulation.
SQ enoxaparin often yields subtherapeutic anti-Xa in STEMI; leaves open optimal dosing for primary PCI.
OBJECTIVE: To evaluate the anticoagulation effect of subcutaneous (SQ) and intravenous (IV) enoxaparin through systematic anti-Xa sampling during primary PCI for acute STEMI. BACKGROUND: Although appropriate anticoagulation is essential to maximize the efficacy and safety of primary PCI, the optimal dosing of enoxaparin in this setting is unclear. METHODS: STEMI patients randomized to primary PCI received ASA, clopidogrel 300 mg and enoxaparin 1 mg/kg SQ at earliest point of care, including prehospital. Plasma anti-Xa determination occurred just prior to and after primary PCI. Supplemental IV enoxaparin (0.3-0.5 mg/kg) and abciximab was encouraged prior to PCI. RESULTS: The 1st anti-Xa level 56 min (median, IQR 47-77) post SQ enoxaparin was 0.28 U/ml (0.23-0.41); 85% of patients (28/33) were <0.5 U/ml (the recommended therapeutic level). Following PCI, 126 min (118-185) after SQ enoxaparin in those without IV dosing (8/33) the 2nd anti-Xa level was 0.44 U/ml (0.29-0.53); 6 of 8 patients remained <0.5 U/ml. With IV enoxaparin (25/33) the 2nd anti-Xa was 0.96 U/ml (0.82-1.16) 97 min (82-109) after SQ enoxaparin: all were >or=0.5 U/ml and 2 had levels 1.5 U/ml. CONCLUSION: A single SQ enoxaparin dose fails to achieve anti-Xa levels >or=0.5 U/ml in the majority of STEMI patients. When combined with a strategy of supplemental IV enoxaparin, adequate anti-Xa levels were achieved in all patients with few having levels >1.5 U/ml. This regime of SQ injection with additional IV enoxaparin provides an attractive strategy enhancing effective early anti-thrombotic therapy at first medical contact prior to primary PCI.
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Welsh et al. (2007) conducted an RCT in ST elevation myocardial infarction (STEMI) (n=33). Supplemental intravenous enoxaparin vs. Subcutaneous enoxaparin alone (1 mg/kg SQ) was evaluated on Achievement of therapeutic anti-Xa level (≥0.5 U/ml) after PCI. Supplemental IV enoxaparin combined with SQ enoxaparin achieved therapeutic anti-Xa levels (≥0.5 U/ml) in 100% of STEMI patients undergoing primary PCI, compared to 25% with SQ enoxaparin alone.
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