The safety of enoxaparine use in elderly with acute myocardial infarction

Background/Aim. Enoxaparin (ENOX), the lowmolecular- weight heparin, used in acute myocardial infarction (AMI) could lead to hemorrhage. The aim of this study was to determine whether bleeding was more often in AMI patients older than 65 or 75 years who receive ENOX or unfractionated heparin (UFH). Methods. Among the patients with AMI hospitalized during three successive months receiving ENOX or UFH, three group of parameters were investigated: demographic, ischemic and bleeding TIMI criteria. Results. Among 85 hospitalized patients with signs of AIM, there were 35 (41.2%) old 65 years or less, 32 (38.5) old 66-75 years and 18 (21.2%) older than 75 years. In AMI elderly patients, according to the received ENOX/UFH: ischemic complication (18.2 vs. 21.4%) were insignificantly lower and the number of lethal outcomes (18,2 vs. 17,8%) were insignificantly more often in ENOX group; represented only by one patient (age beyond 75 years), major and non-major bleeding events occurred only in UFH group. Conclusion. The ENOX usage in AMI in patients older than 65 years did not show any significant difference in efficacy and bleeding rate comparing to UFH.

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History of previous bleeding and C-reactive protein improve assessment of bleeding risk in elderly patients (≥80 years) with myocardial infarction

Thrombosis and Haemostasis ◽

10.1160/th15-05-0395 ◽

2015 ◽

Vol 114 (11) ◽

pp. 1085-1091 ◽

Cited By ~ 8

Author(s):

Lorenz Koller ◽

David-Jonas Rothgerber ◽

Patrick Sulzgruber ◽

Feras El-Hamid ◽

Stefan Forster ◽

...

Keyword(s):

Myocardial Infarction ◽

Elderly Patients ◽

Risk Score ◽

Major Bleeding ◽

Roc Analysis ◽

Bleeding Risk ◽

C Reactive Protein ◽

Bleeding Events ◽

Reactive Protein ◽

History Of

SummaryWe aimed to assess whether the CRUSADE risk score represents a robust instrument for stratification of bleeding risk in elderly myocardial infarction (MI) patients (≥80 years) and further aimed to identify age-specific predictors of major bleeding events. Binary logistic regression models were applied to assess the effect of variables on the occurrence of bleeding events during hospital stay. Receiver operating characteristic (ROC) analysis was used to evaluate the discriminatory power. Out of 387 patients in the final study cohort, 74 patients (19.1 %) experienced a major bleeding event according to the definition of the International Society on Thrombosis and Haemostasis. The CRUSADE risk score demonstrated only a weak discriminatory power to predict bleeding in this group of patients (area under the ROC curve: 0.57 [0.51–0.65]; p=0.05). In the multivariate regression analysis, history of bleeding with an adjusted hazard ratio (HR) of 3.21(95 % confidence interval: 1.29–8.03, p=0.01) and C-reactive protein with an adjusted HR per increase of 10 mg/l of 1.05 (1.01–1.10) were independent predictors of major bleeding. Integration of both variables into the CRUSADE score demonstrated a significantly improved performance for bleeding as indicated by a significant increase in the ROC analysis (area under the curve: 0.64 vs 0.57; for comparison p<0.045), net reclassification index (35.6 0 %; p=0.006) and integrated discrimination increment (0.0242; p=0.02). In conclusion, bleeding history and C-reactive protein significantly improve the modest predictive power of the CRUSADE risk score in elderly patients with MI. These results point towards a specific risk profile for bleeding events in this high-risk group of patients.

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Impact of frailty on outcomes in elderly patients with acute myocardial infarction who undergo percutaneous coronary intervention

European Heart Journal - Quality of Care and Clinical Outcomes ◽

10.1093/ehjqcco/qcaa018 ◽

2020 ◽

Cited By ~ 3

Author(s):

Kensaku Nishihira ◽

Goro Yoshioka ◽

Nehiro Kuriyama ◽

Kenji Ogata ◽

Toshiyuki Kimura ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Percutaneous Coronary Intervention ◽

Elderly Patients ◽

Major Bleeding ◽

Coronary Intervention ◽

Hospital Death ◽

Killip Class ◽

Frail Patients ◽

Percutaneous Coronary

Abstract Aims Frailty is characterized by reduced biological reserves and weakened resistance to stressors, and is common in older adults. This study evaluated the prognostic implications of frailty at hospitalization in elderly patients with acute myocardial infarction (AMI) who undergo percutaneous coronary intervention (PCI). Methods and results We prospectively analysed 546 AMI patients aged ≥80 years undergoing PCI from 2009 to 2017. Frailty was classified based on impairment in walking (unassisted, assisted, and wheelchair/non-ambulatory), cognition (normal, mildly impaired, moderately to severely impaired), and basic activities of daily living. Impairment in each domain was scored as 0, 1, or 2, and patients were categorized into the following three groups based on total score: no frailty (0), mild frailty (1–2), moderate-to-severe frailty (≥3). The median follow-up period was 589 days. Of the 546 patients, 27.8% were frail (mild or moderate-to-severe), and this proportion significantly increased to 35.5% at discharge (P < 0.001). Compared to non-frail patients, frail patients were older, less likely to be male, and had a higher rate of advanced Killip class. Major bleeding (no frailty, 9.6%; mild frailty, 16.9%; moderate-to-severe frailty, 31.8%; P < 0.001) and in-hospital mortality (no frailty, 8.4%; mild frailty, 15.4%; moderate-to-severe frailty, 27.3%; P < 0.001) increased as frailty worsened. After adjusting for confounders, frailty was independently associated with higher mid-term all-cause mortality (hazard ratio, 1.81; 95% confidence interval, 1.23–2.65; P = 0.002). Conclusion Frailty in AMI patients aged ≥80 years undergoing PCI was associated with major bleeding, in-hospital death, and mid-term mortality.

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Heparin Versus Bivalirudin in Acute Myocardial Infarction: Unfractionated Heparin Monotherapy Elevated to Primary Treatment in Contemporary Percutaneous Coronary Intervention

The Open Cardiovascular Medicine Journal ◽

10.2174/1874192401610010122 ◽

2016 ◽

Vol 10 (1) ◽

pp. 122-129

Author(s):

Osmar Antonio Centurión

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Unfractionated Heparin ◽

Major Bleeding ◽

Controlled Trial ◽

Meta Analysis ◽

Bleeding Complications ◽

Thrombin Inhibitor ◽

Strong Argument ◽

Percutaneous Coronary

Bivalirudin, a direct thrombin inhibitor, was developed as an antithrombin agent for patients undergoing percutaneous coronary interventions (PCI) with the hypothesis that it would reduce bleeding complications without compromising the rate of ischemic events compared to heparin plus GP IIb/IIIa inhibitors. Although the cumulative evidence makes a strong argument for the use of bivalirudin rather than heparin plus systematic GP IIb/IIIa inhibitors for the great majority of patients with acute myocardial infarction (AMI) undergoing PCI, the benefit observed with bivalirudin was achieved because of the major bleeding complications with the use of heparin plus GP IIb/IIIa inhibitors. When bivalirudin was compared with unfractionated heparin alone there was no benefit in ischemic complications with a decrease in major bleeding. However, in a recent large randomized controlled trial comparing bivalirudin with unfractionated heparin alone in AMI patients undergoing primary PCI, bivalirudin did not reduce bleeding complications and was associated with higher rates of stent thrombosis, myocardial reinfarction, and repeat revascularization compared with heparin. Moreover, a very recent meta-analysis shed more insights on the utilization of bivalirudin versus heparin regimens during PCI. Findings from this meta-analysis suggest that routine use of bivalirudin offers little advantage over heparin among PCI patients. In a detailed analysis of some randomized trials and observational studies with bivalirudin in AMI patients done by myself and published almost five years ago in this journal, I rendered some reflections on the future widespread use of bivalirudin. “In the setting of PCI in AMI patients, and in the absence of GP IIb/IIIa inhibitors, bivalirudin did not offer any beneficial effect in the incidence of the composite end points when compared with heparin alone. For now, in real world practice, one would probably choose a well known cheaper drug that has already passed the test of time, heparin. There may be reinforcement in the sole utilization of heparin confining GP IIb/IIIa inhibitors and other intravenous antithrombotics to bailout therapy for periprocedural PCI complications in AMI patients”. Therefore, instead of being the beginning of a new era with bivalirudin, it sure is a welcome back to an old friend, heparin. Indeed, after more than two decades, it is always good to welcome back an old friend, unfractionated heparin, as monotherapy and preferred anticoagulant regimen for contemporary PCI in AMI patients.

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Coronary flow and hemorrhagic complications after alteplase and streptokinase administration in patients with acute myocardial infarction

Vojnosanitetski pregled ◽

10.2298/vsp0903218k ◽

2009 ◽

Vol 66 (3) ◽

pp. 218-222

Author(s):

Tomislav Kostic ◽

Zoran Perisic ◽

Dragan Milic ◽

Svetlana Apostolovic ◽

Sonja Salinger-Martinovic ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Major Bleeding ◽

Coronary Flow ◽

Coronary Intervention ◽

Bleeding Complications ◽

Group I ◽

Number Of Patients ◽

Significant Difference ◽

St Elevation

Background/Aim. Up-to-date treatment of acute myocardial infarction (AIM) has been based on as early as possible establishment of circulation in ischemic myocardium whether by the use of fibrinolythic therapy and/or urgent coronary intervention which significantly changes the destiny of patients with AMI, but also increases the risk of bleeding. The aim of this study was to compare coronary flow and bleeding complications in patients with acute myocardial infarction with ST-elevation (STEMI) after administration of alteplase or streptokinase. Methods. The study included 254 patients with STEMI. The group I (n = 174) received streptokinase, and the group II (n = 80) received alteplase. We followed frequency of complications such as bleeding and hypotension in the investigated groups of patients, based on the TIMI classification of bleeding, as well as the transience of infarction artery in accordance with TIMI flow. Results. The patients with myocardial infarction after administration of alteplase had statistically significantly higher coronary flow (TIMI- 3), 72.5% as compared to the patients who received streptokinase, 39.2%. Hypotension as complication of fibrynolythic therapy administration occurred in a significantly higher percentage in the group of patients who received streptokinase. There was no statistically significant difference in the appearance of major bleeding in the groups of patients who received streptokinasis and alteplase (6.9% and 7.5%, respectively). Also, there was no difference in the appearance of minor and minimal bleeding among the investigated groups of patients. Conclusion. It was shown that alteplase in a higher number of patients provided TIMI-3 coronary flow as compared to streptokinese. In comparison with streptokinase, a combination of alteplase, enoxaparin and double antiplatelet therapy enabled earlier achievement of coronary flow through previously blocked coronary artery that was more complete (higher frequency of TIMI-3 flow). There were no statistically significant difference in frequency of bleeding, first of all major bleeding, between the groups treated by alteplase and streptokinase.

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ADP-induced platelet reactivity and bleeding events in patients with acute myocardial infarction complicated by cardiogenic shock

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.155 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

C Scherer ◽

E Luesebrink ◽

S Massberg ◽

D Sibbing ◽

M Orban

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Platelet Aggregation ◽

Cardiogenic Shock ◽

Platelet Reactivity ◽

Bleeding Risk ◽

Left Ventricular ◽

Severe Bleeding ◽

Bleeding Events ◽

Significant Difference

Abstract Funding Acknowledgements Type of funding sources: None. Background While previous reports showed ADP-induced platelet reactivity to be an independent predictor of bleeding after PCI in stable patients, this has never been investigated in patients with cardiogenic shock (CS). Methods The association of bleeding events with respect to ADP-induced platelet aggregation was investigated in patients undergoing primary PCI for acute myocardial infarction complicated by cardiogenic shock (AMI-CS) and with available on-treatment ADP-induced platelet aggregation measurements. Results Out of 233 patients, 74 suffered from a severe BARC 3 or higher bleed. ADP-induced platelet aggregation was significantly lower in patients with BARC≥3 bleedings (10 AU [IQR 3 - 13] vs. 15 AU [IQR 9 - 25], p < 0.001). Multivariate analysis identified on-treatment ADP-induced platelet aggregation as an independent risk factor for bleeding (HR = 0.968 per AU, 95% confidence interval (CI) 0.942-0.994). An optimal cut-off value of <12 AU for ADP-induced platelet aggregation to predict BARC≥3 bleedings was identified via ROC analysis. Moreover, use of VA-ECMO (HR 1.972, 95% CI 1.003-3.879) or coaxial left ventricular pump (HR 2.593, 95% CI 1.509-4.455), first lactate (HR 1.093 per mmol/l, 95% CI 1.037-1.152) and thrombocyte count (HR 0.994 per G/l, 95% CI 0.990-0.998) were independent predictors of BARC≥3 bleedings. There was no significant difference in survival nor ischemic events between patients with low and high on-treatment platelet reactivity. Conclusion: Lower on-treatment ADP-induced platelet aggregation was independently associated with severe bleeding events in patients with AMI-CS. The value of platelet function testing for bleeding risk prediction and guidance of anti-thrombotic treatment in CS warrants further investigation.

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