Fondaparinux and acute coronary syndrome

Fondaparinux is widely used as the anticoagulant of choice in the initial treatment of acute coronary syndrome (ACS). This uptake is largely driven on the results from a large randomized control trial which demonstrated non-inferiority with respect to ischaemic end points but a significant reduction in major bleeding events when compared to enoxaparin in the treatment of ACS. The reduction in bleeding observed is thought to lead to lower mortality rates over time. NICE guidance for the treatment of unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI) suggests that once a diagnosis of UA or NSTEMI is made, a subcutaneous dose of 2.5 mg fondaparinux should be offered (in addition to antiplatelet therapy) to those without a high bleeding risk, and continued daily for a maximum of eight days or hospital discharge if this occurs earlier. For patients where coronary angiography is planned within 24 hours, fondaparinux should be withheld and another heparin (usually unfractionated heparin) considered due to a small but significant risk of catheter related thrombus.