Treatment of Vulnerable Plaques: Current and Future Strategies
Levon Michael Khachigian in High-Risk Atherosclerotic Plaques, 2004
The greater efficacy of enoxaparin over unfractionated heparin may relate to the former agent’s more potent action on the proximal component of the coagulation cascade, factor Xa, or, more likely, the more favorable pharmacokinetic profile of the anticoagulant activity of low molecular weight heparin. The anti-inflammatory activities of both drugs may have additional differences. In a randomized comparison with unfractionated heparin, enoxaparin suppressed neutrophil-induced elastase release and complement activation more effectively in a simulated extracorporeal circulation.89 It is possible that the persistence of low molecular weight products with anticoagulant activities following administration of enoxaparin mediate this prolonged therapeutic effect.90 The impacts of these small molecules on inflammatory activities have not been addressed.
Peri- and Postoperative Care
Linda Cardozo, Staskin David in Textbook of Female Urology and Urogynecology - Two-Volume Set, 2017
Low risk AtriAl fibrillAtion MitrAl vAlve diseAse CArdiomyopAthy venous or ArteriAl thromboembolism MechAnicAl vAlve replAcement stop wArfArin 4 dAys prior to procedure. If immobilized, use prophylActic enoxApArin, 40 stop wArfArin 4 dAys prior to procedure. InitiAte intrAvenous hepArin or enoxApArin treAtment dose when Inr < 2.0. stop intrAvenous hepArin 3 hours preop. If on enoxApArin, withhold dose on dAy of operAtion/procedure. ProphylActic dose of enoxApArin. restArt wArfArin post-op if hemostAsis is secure. stop enoxApArin when internAtionAl normAlised rAtio (Inr) > 2.0. restArt intrAvenous hepArin 6 hours post-op if hemostAsis is secure (do not give loAding dose); check APtt After 12 hours or subcutAneous enoxApArin treAtment dose. restArt wArfArin when AppropriAte. stop enoxApArin/hepArin when Inr > 2.0.
Adjunctive pharmacotherapy and coronary intervention
Ever D. Grech in Practical Interventional Cardiology, 2017
A recent high-quality meta-analysis examined multiple clinical trials to compare the relative safety and efficacy of enoxaparin to UFH in PCI.34 Notably, it included over 30,000 patients and captured a full spectrum of PCI populations (from stable angina patients undergoing elective PCI to primary PCI in STEMI). Enoxaparin was associated with significant reductions in death (relative risk [RR] 0.66; 95% CI 0.57–0.76; p < .001), composite endpoint of death and MI (RR 0.68; 95% CI 0.57–0.81; p < .001) and major bleeding (RR 0.80; 95% CI 0.60–0.85; p < .001). In sub-group analyses, enoxaparin's mortality benefit was primarily driven by patients with STEMI, although non-statistically significant trends towards lower mortality were also seen in both elective PCI and NSTE ACS patient populations. All PCI groups, however, consistently demonstrated statistically significant reductions in bleeding with enoxaparin compared with UFH. Notable limitations of this meta-analysis include that it was not performed with individual patients’ data, approximately one-third of the patients included came from studies that were not randomised, and P2Y12 usage patterns, such as pre-treatment, are not well detailed. However, we still believe its conclusions are robust and valid.
Anticoagulation in COVID-19: a single-center retrospective study
Published in Journal of Community Hospital Internal Medicine Perspectives, 2021
Sohaib Sanan Roomi, Maryum Saddique, Waqas Ullah, Shujaul Haq, Ammar Ashfaq, John Madara, Margot Boigon
The preferred anticoagulation therapy in hospitalized COVID-19 patients is subcutaneous heparin or enoxaparin. Warfarin and Direct Oral Anticoagulants (DOACs) are less efficacious due to COVID 19-related hepatic dysfunction and reduced oral intake which may affect absorption or response to warfarin [7]. Enoxaparin has also shown to possess anti-viral properties in vitro and its anti-inflammatory characteristics are believed to circumvent the activation of coagulation cascade induced by inflammation in the setting of cytokine release syndrome and overall proinflammatory state of COVID-19 [8]. Our hospital, following the guidelines of its parent enterprise, advocated for therapeutic anticoagulation for all the COVID-19 patients who had an alternative indication for anticoagulation or those having high clinical suspicion of thrombosis without objective evidence as diagnostic testing was limited in COVID-19 patients. Very high inflammatory markers, particularly the D-dimer level, were also used as a surrogate marker for therapeutic anticoagulation in the right clinical settings. In our patient population, enoxaparin was used in both therapeutic anticoagulation and prophylactic anticoagulation arms. Heparin was used in renal insufficiency and DOACs were continued if a particular patient was already on them due to an alternative indication like atrial fibrillation or deep venous thrombosis, etc.
Heparin-bridging therapy is associated with post-colorectal polypectomy bleeding in patients whose oral anticoagulation therapy is interrupted
Published in Scandinavian Journal of Gastroenterology, 2018
Taishi Sakai, Yasuaki Nagami, Masatsugu Shiba, Kappei Hayashi, Yosuke Kinoshita, Hirotsugu Maruyama, Kunihiro Kato, Hiroaki Minamino, Masaki Ominami, Shusei Fukunaga, Koji Otani, Shuhei Hosomi, Fumio Tanaka, Koichi Taira, Noriko Kamata, Hirokazu Yamagami, Tetsuya Tanigawa, Toshio Watanabe, Yasuhiro Fujiwara
The reasons underlying the increase in post-procedure bleeding associated with heparin-bridging therapy are unclear. Some investigators have hypothesized that if patients who are receiving full-dose anticoagulation are undergoing surgery, any abnormal bleeding would be detected and handled during the procedure. On the other hand, bleeding caused by heparin is only detected during the postoperative period, when the full anticoagulation effect has occurred and the surgical wound has been closed. This phenomenon has been called an ‘anticoagulant stress test’ [6]. In addition, the use of warfarin and heparin may temporarily overload anticoagulant activity, thereby affecting PPB [8]. Recently, the use of continuous warfarin at the time of pacemaker or implantable cardioverter-defibrillator surgery reduced the incidence of hematoma formation compared to heparin-bridging therapy [6]. Conversely, interrupting warfarin treatment in patients with atrial fibrillation was not inferior to heparin-bridging therapy with respect to preventing arterial thromboembolism [24]. These alternative approaches may encourage a range of comparisons with heparin-bridging therapy in colonoscopic polypectomy. In the US, enoxaparin is widely used as a bridging therapy. Since enoxaparin is not an insurance indication in Japan, enoxaparin was not used.
Bivalirudin during percutaneous coronary intervention in acute coronary syndromes
Published in Expert Opinion on Pharmacotherapy, 2019
Marc Laine, Gilles Lemesle, Thibaut Dabry, Vassili Panagides, Michael Peyrol, Franck Paganelli, Laurent Bonello
The ATOLL trial failed to prove the superiority of enoxaparin compared to UFH [3]. In this trial, 910 STEMI patients undergoing primary PCI were randomly assigned to receive UFH or LMWH. The primary end point was a composite of 30-day death, complication of myocardial infarction, procedural failure of bleedings. It occurred in 28% of patients treated with enoxaparin compared to 34% of the patients in the control group (RR: 0.83; 95%CI (0.68–1.01), p = 0.06). A strong signal emerged from this study: a reduction was found in the rate of the main secondary end point composed of death, recurrent ACS or urgent revascularization (7% enoxaparin group vs 11%, RR: 0.59; 95%CI (0.38–0.91), p = 0.03). However, because of the neutral result of this study on its primary end point, international guidelines do not recommend enoxaparin as first line agent in STEMI patients undergoing primary PCI [1].
Related Knowledge Centers
- Acute Coronary Syndrome
- Anticoagulant
- Deep Vein Thrombosis
- Edema
- Lumbar Puncture
- Myocardial Infarction
- Pulmonary Embolism
- Pregnancy
- Subcutaneous Administration
- Intravenous Therapy