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![Page 1: Major Hemorrhagic Events (Acute Phase) No significant increase in rate of major hemorrhage 0 20 40 60 ESSENCE n = 3171 TIMI 11B n = 3910.](https://reader035.fdocuments.in/reader035/viewer/2022062407/56649cf05503460f949bf5ec/html5/thumbnails/1.jpg)
ESSENCE
Study DesignStudy Design
Enoxaparin1 mg/kg every
12 h subcutaneous
+ ASA
UFHIV dose
adjusted + ASA
Unstable anginaUnstable anginaNonNon--QQ--wave MIwave MI
Treatment phaseminimum 48 h
maximum 8 days
Follow-up phaseMI, myocardial infarctionASA, acetylsalicylic acid UFH, unfractionated heparinIV, intravenous
Cohen M, et al. N Engl J Med 1997;337:447-52
‡Goodman SG, et al. J Am Coll Cardiol 2000 (in press)
FollowFollow--up up callcall
1 Year1 Year‡‡
FollowFollow--up up callcall
Day 30Day 30
FollowFollow--up up visitvisit
Day 14Day 14
FollowFollow--up up callcall
Day 30Day 30
FollowFollow--up up visitvisit
Day 14Day 14
FollowFollow--up up callcall
1 Year1 Year‡‡
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2525
2020
1515
1010
55
00
22 44 66 88 1010 1212 1414 1616 1818 2020 2222 2424 2626 2828 3030
UFHEnoxaparin
Days from randomizationDays from randomization
% o
f pa
tient
s w
ith e
ven
ts%
of
patie
nts
with
eve
nts
P=0.019
P=0.017
Cohen M, et al. N Engl J Med 1997;337:447-52
MI, myocardial infarctionRA, recurrent anginaUFH, unfractionated heparin
Time to First Event over 30 Days: Death, MI, Recurrent AnginaTime to First Event over 30 Days: Death, MI, Recurrent AnginaSuperiority ofSuperiority of enoxaparinenoxaparin was maintained to 30 dayswas maintained to 30 days
15 % Risk Reduction
LMWH in ACS LMWH in ACS -- ESSENCE trail ESSENCE trail
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ESSENCE
0
5
10
15
20
25
30
35
0 2 4 6 8 10 12 14
MonthsMonths
Cu
mu
lati
ve
eve
nt
rate
(%
)C
um
ula
tiv
e ev
en
t ra
te (
%)
1-YEAR FOLLOW-UP
MI, myocardial infarction
RA, recurrent angina
UFH, unfractionated heparin
Time to Event at 1 Year: Death, MI, Recurrent AnginaTime to Event at 1 Year: Death, MI, Recurrent Angina
Superior efficacy ofSuperior efficacy of enoxaparinenoxaparin was maintained to 1 yearwas maintained to 1 year
Enoxaparin
UFH
Fox KAA. Heart 1998;82: I12-I14
P = 0.02
P = 0.02
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ESSENCE
SafetySafetyRisk of majorRisk of major haemorrhagichaemorrhagic events was similar in both groupsevents was similar in both groups
HaemorrhageHaemorrhageMajorMajor 107 (7.0%)107 (7.0%) 102 (6.5%)102 (6.5%) 0.570.57MinorMinor 110 (7.2%)110 (7.2%) 188 (11.9%)188 (11.9%) < 0.001< 0.001
StrokeStroke 7 (0.5%)7 (0.5%) 7 (0.4%)7 (0.4%) NSNSHaemorrhagicHaemorrhagic 1 (0.1%)1 (0.1%) 00 NSNSNonNon--haemorrhagichaemorrhagic 6 (0.4%)6 (0.4%) 7 (0.4%)7 (0.4%) NSNS
TransientTransient ischaemicischaemic attackattack 8 (0.5%)8 (0.5%) 1 (0.1%)1 (0.1%) NSNS
Drop in platelet countDrop in platelet count 56 (3.7%)56 (3.7%) 39 (2.5%)39 (2.5%) 0.080.08(> 50% from baseline)(> 50% from baseline)
UFHUFH EnoxaparinEnoxaparin P P valuevalue((nn=1529)=1529) ((nn=1578)=1578)
Cohen M, et al. N Engl J Med 1997;337:447-52UFH, unfractionated heparinNS, non-significant
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TIMI 11BTime to First Event (Triple Endpoint): Acute PhaseTime to First Event (Triple Endpoint): Acute Phase
Event rate significantly reduced at 48 h in enoxaparin groupEvent rate significantly reduced at 48 h in enoxaparin group
10 10 –
8 8 –
6 6 –
4 4 –
2 2 –
0088 1616 3232 4040 4848 5656 7272
UFHEnoxaparin
Hours from randomizationHours from randomization
% o
f p
ati
en
ts w
ith
eve
nts
% o
f p
ati
en
ts w
ith
eve
nts 7.3%
5.5%
Relative risk reduction 23.8%
P=0.029
Triple endpoint, death/myocardial infarction/urgent revascularization UFH, unfractionated heparin
Antman EM, et al. Circulation
1999;100:1593-1601
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TIMI 11B
Time to First Event (Triple Endpoint): Chronic PhaseTime to First Event (Triple Endpoint): Chronic PhaseEarly treatment benefit of enoxaparin sustained over 14 daysEarly treatment benefit of enoxaparin sustained over 14 days
UFHEnoxaparin
Days from randomizationDays from randomization
% o
f p
ati
en
ts w
ith
eve
nts
% o
f p
ati
en
ts w
ith
eve
nts 14.5%
12.4%
Relative risk reduction 15%P=0.048
16.7%
14.2%
44
88
1212
1616
2020
00 22 44 66 88 1010 1212 1414
Antman EM, et al.
Circulation 1999;100:1593-1601
Triple endpoint, death/myocardial infarction/urgent revascularization UFH, unfractionated heparin
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TIMI 11B
Time to First Event (Triple Endpoint): Chronic PhaseTime to First Event (Triple Endpoint): Chronic PhaseSuperior efficacy of enoxaparin maintained to 43 daysSuperior efficacy of enoxaparin maintained to 43 days
UFHEnoxaparin
Days from randomizationDays from randomization
% o
f p
ati
en
ts w
ith
eve
nts
% o
f p
ati
en
ts w
ith
eve
nts
Relative risk reduction 12%P=0.048
19.7%
17.3%
44
88
1212
1616
2020
00 88 1616 2424 3232 4040 4343
Antman EM, et al.
Circulation 1999;100:1593-1601
Triple endpoint, death/myocardial infarction/urgent revascularization UFH, unfractionated heparin
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Major Hemorrhagic Events (Acute Phase) No significant increase in rate of major hemorrhage
0
20
40
60
ESSENCEn = 3171
TIMI 11Bn = 3910
TESSMAn = 7081
UFHEnoxaparin
Antman EM et al. Circulation 1999;100:1602-8UFH, unfractionated heparin; NS, not significant
NS
NS
NS
Num
ber o
f pati
ents
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GUSTO VBenefit vs. risk
Death or re-MISevere / moderate
hemorrhage
Reteplase
Abciximab+ reteplase
8.8%
7.4%
2.3%
4.6%
D = 2.3%P < 0.001
D = 1.4%P = 0.001
0 2 4 6 8 10246Percentage of patients
GUSTO V Investigators. Lancet. 2001;357:1905.
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FRAXIS2 (nadroparin)n=3468
FRIC3 (dalteparin)n=1482
TIMI 11B4 (enoxaparin)n=3910
ESSENCE5 (enoxaparin)n=3171
RRR-20% -15% -10% -5% 0% 5% 10% 15% 20%
3.9%
0%
-14.9%
-16.2%
1. Cohen M. Semin Thromb Hemost 1999;25(suppl 3):113-212. The FRAXIS study group. Eur Heart J 1999;20:1553-62 3. Klein W, et al. Circulation 1997;96:61-8 4. Antman EM, et al. Circulation 1999;100:1593-601 5. Cohen M, et al N Engl J Med 1997;337:447-52
LMWH superior UFH superior
Non ST Elevation MI/ Unstable Angina Non ST Elevation MI/ Unstable Angina Myocardial Infarction: Composite Endpoints Myocardial Infarction: Composite Endpoints
at 14 Daysat 14 Days11
Relative RiskRatio (RRR) Significance
NS
P=0.03
P=0.02
NS
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LowLow--MolecularMolecular--Weight HeparinsWeight HeparinsAnti-Facotr Xa : Anti - Factor IIa Ratios
Agent Trade Xa:IIa Mol Wt (d)
Enoxaparin Lovenox 3.8 : 1 4,200Dalteparin Fragmin 2.7 : 1 6,000Ardeparin Normiflo 1.9 : 1 6,000Nadroparin 3.6 : 1 4,500Reviparin 3.5 : 1 4,000Tinzaparin 1.9 : 1 4,500
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MontalescotG, et al. JAmColl Cardiol2000;36:110-4
vWF(%)
100
80
60
40
20
0
P=0.0006
Dalteparin120 IU anti-Xa/kg bid
Enoxaparin1 mg/kg (100 IU anti-Xa/kg) bid
UFH 5000 IU anti-Xai.v. bolus thenaPTT-adjusted continuous infusion
NS
Release of vonRelease of vonWillebrandWillebrandFactor (Factor (vWFvWF))
Enoxaparinreleases lessvWF, resulting in reduced
platelet aggregation compared with UFH ordalteparinat approved treatment doses for unstable angina/
non-Q-wave myocardial infarction
UFH,unfractionatedheparin LMWH, low-molecular-weight heparinaPTT, activated partialthromboplastintime
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Low-Molecular-Weight Heparin
Indirect thrombin inhibitorLess reversibleDifficult to monitor
(no aPTT or ACT)Renally clearedLong half-lifeRisk of HIT
DisadvantagesIncreased anti-Xa to anti-IIa
activity inhibits thrombin generation more effectively
Induces ↑ release of TFPI vs UFH
Not neutralized by platelet factor 4
Less binding to plasma proteins (eg, acute-phase reactant proteins) more
consistent anticoagulationLower rate of HIT vs UFH Lower fibrinogen levels Easy to administer (SC
administration)Long history of clinical
studies and experience, FDA-approved indications
Monitoring typically unnecessary
Advantages
Hirsh J, et al. Circulation. 2001;103:2994-3018. TFPI = tissue factor pathway inhibitor; UFH = unfractionated heparin; SC = subcutaneous; aPTT = activated partial thromboplastin time ;
ACT = activated coagulation time.
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ATIIa
Hep
UFH
IIaS
C
Direct antithrombin
LMWH
AT Xa
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Clot Burden in ACS patient
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Heparin fails to effectively inhibit Clot-bound Thrombin
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Bivalirudin inhibitsClot-Bound and Circulating Thrombin
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Bivalirudin Does not activate Platelets
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Bivalirudin: Unique mechanism of action overcomes the limitation of Heparin
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Compared to Heparin/Enoxaparin with GP IIb/IIa inhibitors,Bivalirudin monotherapy significantly reduces major bleeding while providing similar ischemic protection, and improves net clinical
outcome.
Bivalirudin Advantage
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ATIIa
Hep
UFH
IIaS
C
Direct antithrombin
LMWH
AT Xa AT Xa
Pentasaccharide
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IIa II
Fibrinogen Fibrin clot
Extrinsic pathway
Intrinsicpathway
AT XaAT AT
Fondaparinux
Xa
Antithrombin
Fondaparinux: A Synthetic Factor Xa Inhibitor
Adapted with permission from Turpie AGG et al. N Engl J Med. 2001;344:619.
THROMBIN
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Key Steps in Coagulation Pathway
Inhibition of one molecule of factor Xa can inhibit the
generation of 50 molecules of thrombin2
Intrinsic pathway Extrinsic pathway
1 .Rosenberg RD, Aird WC. N Engl J Med 1999;340(20):1555–64.2 .Wessler S, Yin ET. Thrombo Diath Haemorrh 1974;32(1):71–8.
Intrinsic pathway
1
50
Xa X
II
FibrinFibrinogen
Clot
Xa
Va
PL
Ca2+
IIa
VIIIa
Ca2+
PL
IXa
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Herbert JM et al. Cardiovasc Drug Rev. 1997;15:1 .van Boeckel CAA et al. Angew Chem, Int Ed Engl. 1993;32:1671 .
·Once daily administration ·Rapid onset (Cmax/2=25 min)·Half life: 15-18 h.·Effects reversible with administration
of activated Factor VII (Novoseven®)·No liver metabolism·Renal clearance·No protein binding (other than AT)·No reported cases of HIT·No dose adjustment necessary in
elderly
Fondaparinux: A Synthetic Inhibitor of Factor Xa
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12,000 Patients with STEMI < 12 h of symptom onset:Inclusion ST mm prec leads or 2 mm limb leads 1
:ExclusionContra-ind. for anticoagulant, INR>1.8, pregnancy, ICH<12 mo .
12,000 Patients with STEMI < 12 h of symptom onsetInclusion: ST 2 mm prec leads or 1 mm limb leads
Exclusion: Contra-ind. for anticoagulant, INR>1.8, pregnancy, ICH<12 mo.
UFH not indicatedUFH not indicated
OASIS-6: Randomized, Double Blind
Lytics (SK, TPA, TNK, RPA), Primary PCI or no reperfusion (eg. late)Lytics (SK, TPA, TNK, RPA), Primary PCI or no reperfusion (eg. late)
StratificationStratification
UFH indicatedUFH indicatedRandomization Randomization
Fondaparinux2.5 mg Placebo
Fondaparinux2.5 mg UFH
JAMA 2006;295:1519-30
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Primary Efficacy OutcomeDeath/MI at 30 Days
Days
Cum
ulati
ve H
azar
d0.
00.
020.
040.
060.
080.
100.
12
0 3 6 9 12 15 18 21 24 27 30
UFH/Placebo
Fondaparinux
HR 0.86 95% CI 0.77-0.96
P=0.008
The OASIS-6 Trial Group. JAMA 2006;295:1519-30
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Death or MI 3 or 6 months
Days
Cum
ulati
ve H
azar
d
0.0
0.02
0.04
0.06
0.08
0.10
0.12
0 18 36 54 72 90 108 126 144 162 180
UFH/Placebo
Fondaparinux
HR 0.88 95% CI 0.79-0.99
P=0.029
The OASIS-6 Trial Group. JAMA 2006;295:1519-30
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•Primary :Efficacy:Death, MI, refractory ischemia day 9
Safety:Major bleeds
Risk benefit:Death, MI, refractory ischemia, major bleeds •SecondaryAbove & each component (especially deaths) at 30 & 180 d :•HypothesisFirst test non-inferiority, then test superiority :
•Primary: Efficacy: Death, MI, refractory ischemia 9 day
Safety: Major bleeds
Risk benefit: Death, MI, refractory ischemia, major bleeds•Secondary: Above & each component (especially deaths) at 30 & 180 d•Hypothesis: First test non-inferiority, then test superiority
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Death at 6 Months
Days
Cum
ulati
ve H
azar
d0.
00.
020.
040.
06
0 20 40 60 80 100 120 140 160 180
HR 0.8995% CI 0.79-0.99
p=0.037
Enoxaparin
Fondaparinux
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Death or MI: 6 Months
Days
Cum
ulati
ve H
azar
d
0.0
0.02
0.04
0.06
0.08
0.10
0.12
0 20 40 60 80 100 120 140 160 180
HR 0.9195% CI 0.84-0.99
p=0.036
Enoxaparin
Fondaparinux
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Major Bleeding: 6 Months
Days
Cum
ulati
ve H
azar
d
0.0
0.01
0.02
0.03
0.04
0.05
0.06
0 20 40 60 80 100 120 140 160 180
HR 0.7295% CI 0.63-0.82
p<<0.00001
Enoxaparin
Fondaparinux
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Death, MI, RI or Major Bleeding at 6 Months
Days
Cum
ulati
ve H
azar
d0.
00.
050.
100.
15
0 20 40 60 80 100 120 140 160 180
Enoxaparin
Fondaparinux
HR 0.8795% CI 0.81-0.93
p<<0.00001
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Fondaparinux
•Difficult to monitor (no aPTT or ACT)
•Long half-life•Catheter thrombosis
during PCI
DisadvantagesAdvantages•SC administration
―Potential exists for outpatient
management•Once-daily
administration•Predictable
anticoagulant response•Fixed dose•No antigenicity•Potentially no need for
serologic parameters•Does not cross the
placenta•HIT antibodies do not
cross-react•Decreased bleeding
complications vs UFH or LMWH
Simoons ML, et al. J Am Coll Cardiol. 2004;43:2183-2190.Yusuf S, et al. N Engl J Med. 2066;354:1464-1476 .