Non-inferiority of Enoxaparin compared to unfractionated Heparin in the treatment of unstable angina and NSTEMI.

Abstract

URANIA CASSAR Context: Antithrombin therapy in patients with Unstable Angina (UA) and non ST-segment elevation myocardial infarction (NSTEMI) Acute Coronary Syndrome (ACS) consists of either unfractionated heparin (UFH) or low molecular weight heparin (LMWH) such as Enoxaparin. As from 2001, the latter has become the rationale treatment for these conditions in local hospitals under the trade name 'Clexane'. Objective: To seek evidence on the efficacy and safety of administering Enoxaparin anti comparatively of administering UFH for patients diagnosed with UA or NSTEMI. The PICO question discussed is 'In patients with UA and NSTEMI, how does the efficacy and safety of Enoxaparin compare to that of unfractionated heparin?' The method: A literature search was conducted by breaking up the PICO question into key words in relation to the patient population, intervention and comparative treatment and the outcomes. Exclusion and inclusion criteria applied yielded 4 randomized controlled trials (RCTs) and I systematic overview (SO) as the best available evidence on the topic. The Critical Appraisal Skills Programme (CASP) tool was used in the appraisal of this literature. The overall findings: From the analysis carried out on a total of 20,674 patients treated with either anticoagulant in these studies, enoxaparin fell well within the bounds for non-inferiority to UFH in all outcomes. Whereas similar mortality rates were recorded, the combined efficacy end point of all-cause death and nonfatal new MI was to its advantage. Moreover, no excess in blood transfusion and major bleeding was reported with statistical significance, although an increased rate of minor bleeding has been recognized. Implications and Recommendations: During clinical practice, the predictable anticoagulant response of the subcutaneous dosing with enoxaparin provides a number of advantages like no requirement for activated partial thromboplastin time (aPTT) monitoring. However, this treatment is contraindicated in some conditions like renal insufficiency or when full and rapid reversal procedures of anticoagulation are required. Clear local protocols with periodic updates and policy development, possibly based on data from local research, are to be disseminated on hospital intranet (e.g. KURA) to guide management of patients with ACS. Further education for healthcare professionals, update in nursing student programs and information leaflets for patients and their relatives to share best evidence based practice are warranted.