American Heart Association: Superior Outcomes in STEMI after Low-Molecular-Weight Heparin

13 Apr
2010

Speaker: Marc S. Sabatine, MD, Associate Physician, Cardiovascular Division, Brigham & Women’s Hospital, and Instructor in Medicine, Harvard Medical School, Boston, Massachusetts

The use of a low-molecular-weight heparin (LMWH) plus other standard therapies, including aspirin and clopidogrel (Plavix) may be associated with improved angiographic outcomes, lower rates of major adverse cardiovascular events, and an absence of excessive major bleeding, compared with the use of unfractionated heparin (UFH) in patients with ST-segment elevation myocardial infarction (STEMI).

It is known that LMWH has pharmacological and practical advantages over UFH, but whether this translates into improved infarct-related artery patency and fewer adverse clinical events in patients with STEMI is still under study. canadian antibiotics

A subgroup analysis was conducted on data from the CLARITY-TIMI 28 (CLopidogrel as Adjunctive ieperfuslon Therap^Thrombolysis In Л/yocardial Infarction) study. This was a randomized trial of clopidogrel versus placebo in 3,491 STEMI patients younger than 75 years of age who were receiving a standard fibrinolytic regimen, including aspirin.

For this protocol, all patients were to undergo angiography at two to eight days. Study endpoints included patency of the infarct-related artery or death or MI before angiography and clinical events through 30 days.

In the LMWH group (1,429 patients), 85% received enoxa-parin (Lovenox, Sanofi Aventis); 13% received nadroparin (Fraxiparine, Sanofi Canada [not available in the U.S.]; and 2% received another LMWH. A total of 1,431 patients received UFH.

Treatment with LMWH, compared with UFH, was associated with significantly lower rates of both (1) a closed artery or death or MI before angiography (12.5% vs. 22.5%) respectively, and (2) cardiovascular death or MI through 30 days (6.9% vs. 11.5%), respectively. TIMI major bleeding was similar in the LMWH group and in those receiving UFH (1.6% vs. 2.2%); intracranial hemorrhage was also similar (0.6 vs. 0.8%).

Pioglitazone Reduces Risk of a Second Myocardial Infarction in Type-2 Diabetes

Speaker: Erland Erdimann, MD, Professor, University of Cologne, and Director, Third Clinic for Internal Medicine, Cologne, Germany

Pioglitazone (Takeda), a well-known thiazolidine-dione used as an adjunct to diet and exercise in type-2 diabetes mellitus, can significantly reduce the risk of a second myo-cardial infarction (MI) in patients with type-2 diabetes and a pre-existing MI when compared with placebo.

To determine whether pioglitazone might reduce total mortality and macrovascular morbidity in high-risk patients with type-2 diabetes, researchers conducted a trial entitled The Effect of Pioglitazone on Recurrent Myocardial Infarction in 2,445 Patients with Type 2 Diabetes and Pre-existing Myocardial Infarction: Data from the PROactive (PROspective PioglitAzone Clinical Trial in MacroFascular .Events) Study.

This study was a subanalysis of data from the larger PROactive clinical trial, which investigated the effect of canadian pioglitazone on macrovascular disease in type-2 diabetes.

In this multicenter, randomized, double-blind, placebo-controlled, parallel-group phase 3 clinical trial, approximately 5,000 patients with type-2 diabetes at increased risk of macrovascular disease were randomly selected to use pio-glitazone. The dose was increased stepwise from 15 to 30 to 45 mg, depending on tolerability, or placebo daily, given in addition to current antidiabetic drugs and other medications.

In the PROactive trial, pioglitazone reduced the risk of heart attacks, strokes, and premature death by 16%.

In the subgroup analysis, the type-2 diabetic patients with pre-existing MIs were observed for 2.5 years. The investigators calculated that giving pioglitazone to 1,000 patients who had type-2 diabetes and a previous heart attack would prevent 22 recurrent MIs over three years. In addition, there was a 37% decrease in acute coronary syndrome (ACS) with pioglita-zone. ACS represents a spectrum of ischemic heart symptomatology ranging from unstable angina to non-STEMI.

Also well tolerated. The tolerability profile in the subgroup analysis was similar to that observed in the other study, and there were no unexpected adverse events.

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