Fondaparinux vs LMWH in NSTEMI | Journal Scan

Study Questions:

What is the association between the use of fondaparinux versus low molecular weight heparin (LMWH) and outcomes in patients with non–ST-segment elevation myocardial infarction (NSTEMI) in Sweden?

Methods:

This was a registry study from Sweden involving 40,616 consecutive patients with NSTEMI who received fondaparinux or LMWH between September 1, 2006 and June 30, 2010. In-hospital treatment with fondaparinux or LMWH during the hospital stay was compared. The main outcome measures were in-hospital severe bleeding events and death and 30- and 180-day death, MI, stroke, and major bleeding events. Logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI) for having an event at each time point for patients treated with fondaparinux compared with those treated with LMWH.

Results:

In total, 14,791 patients (36.4%) were treated with fondaparinux and 25,825 (63.6%) with LMWH. One hundred sixty-five patients (1.1%) in the fondaparinux group versus 461 patients (1.8%) in the LMWH group experienced in-hospital bleeding events (adjusted OR, 0.54; 95% CI, 0.42-0.70). A total of 394 patients (2.7%) in the fondaparinux group died while in the hospital versus 1,022 (4.0%) in the LMWH group (adjusted OR, 0.75; 95% CI, 0.63-0.89). The differences in major bleeding events and mortality between the two treatments were similar at 30 and 180 days. There were no significant differences in the number of recurrent MI and stroke events at 30 or 180 days among the two treatment groups.

Conclusions:

The authors concluded that in routine clinical care of patients with NSTEMI, fondaparinux was associated with lower odds than LMWH of major bleeding events and death both in-hospital and up to 180 days afterward.

Perspective:

This study compared the anticoagulant fondaparinux with LMWH in a nationwide registry of patients with NSTEMI treated in routine clinical care. The study reports that the use of fondaparinux, compared with LMWH, was associated with a lower risk of bleeding events and death both in short- and long-term follow-up, but with similar rates of MI and stroke. The results support current American College of Cardiology/American Heart Association guidelines, which recommend that either fondaparinux or enoxaparin be used for patients with acute coronary syndrome who do not undergo percutaneous coronary intervention (PCI). It should be noted that fondaparinux was associated with a small, but significant increase in catheter-related thrombi (in patients undergoing PCI) compared to enoxaparin in the OASIS-5 trial. To avert catheter thrombosis when fondaparinux is used alone in patients undergoing PCI, an anticoagulant with anti-IIa activity also needs to be administered.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Invasive Cardiovascular Angiography and Intervention, Anticoagulation Management and ACS, Interventions and ACS

Keywords: Acute Coronary Syndrome, Anticoagulants, Enoxaparin, Heparin, Low-Molecular-Weight, Length of Stay, Myocardial Infarction, Outcome Assessment (Health Care), Percutaneous Coronary Intervention, Stroke, Thrombosis, Registries, Logistic Models


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