The treatment of ST-segment elevation acute coronary syndromes (STEACS) is undoubtedly reperfusion therapy with primary percutaneous coronary intervention. Similarly, nobody doubts that the pretreatment with more stronger antiplatelet agents has a role in such a treatment. In certain sites, unfractionated heparin (UFH) pretreatment is also administered before the patient enters the cath lab; its aim is to reduce thrombotic charge.
While its peak effect is reached within minutes after systemic administration, its half-life is only 1-2 hours. Current guidelines recommend its use in the cath lab, with adequate active coagulation time control.
The purpose of this study was to determine the relative risks for the clinical endpoints in the pretreatment with UFH, including coronary occlusion at the time of coronary angiography, 30-day mortality, and major in-hospital bleeding. The studied cohort was part of the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). The most frequently used UFH dose was 5000 IU.
A total of 41,631 patients were enrolled: 16,026 (38%) received the pretreatment and 25,605 (62%) did not. The mean patient age was 67 years old, and 71% of patients were male. Among all patients, 66% had coronary occlusion, 6.5% died within 30 days, and 2.1% suffered some type of major in-hospital bleeding.
Overall, the pretreatment group experienced an 11-% decrease in risk. The adjusted risk ratios were 0.89 (95% confidence interval [CI]: 0.87 to 0.90) for coronary artery occlusion, 0.87 (95% CI: 0.77 to 0.99) for mortality, and 1.01 (95% CI: 0.86 to 1.18) for bleeding. Researchers conducted propensity score analyses, one for coronary artery occlusion, and another for mortality and bleeding. The absolute risk difference for coronary artery occlusion was significantly lower with the pretreatment: −0.087 (95% CI: −0.074 to −0.099). The same happened with mortality: −0.011 (95% CI: −0.017 to −0.0041).
Conclusions
In this Swedish registry, with a large patient sample, there was an 11-% reduction in coronary occlusion in patients with STEACS, with a number needed to treat of 12, without significantly increasing the risk of bleeding. While these data are consistent with previous studies, they are relevant because of the number of included patients.
However, limitations of this study include being an observational study and not specifying the time of heparin administration. As such, this strategy should be supported by a randomized study.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Font: Emilsson, Oskar Love et al. “Pretreatment with heparin in patients with ST-segment elevation myocardial infarction: a report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR).” EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology, EIJ-D-22-00432. 29 Aug. 2022, doi:10.4244/EIJ-D-22-00432.
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