Opposition: Unfractionated heparin should no longer be used in the catheterization laboratory
The goal of anticoagulation during percutaneous coronary intervention (PCI) is the primary and secondary prevention of thrombotic and significant bleeding events that increase cardiovascular morbidity and mortality. Unfractionated heparin is the most commonly-used anticoagulant, but low-molecular weight heparin, and more recently bivalirudin are becoming increasingly popular in cardiac catheterization laboratories1.
The ACC/AHA/SCAI PCI guidelines2 recommend a 70-100 IU/kg bolus of heparin to achieve an activated clotting time (ACT) of 250-300 seconds for Hemotec and 300-350 seconds for Hemochron systems, when glycoprotein IIb/IIIa inhibitors are not used. When glycoprotein IIb/IIIa inhibitors are used, a bolus of 50-70 IU/kg of unfractionated heparin is recommended to achieve an ACT of 200-250 seconds.
- Appleton DL, Cooke RH, Rao SV, Jovin IS. Anticoagulation in transradial percutaneous coronary intervention. Catheter Cardiovasc Interv 2014;83(2):237–42. CrossRef
- Levine GN, Bate ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011;124: e574–e651. CrossRef
- White HD, Kleiman NS, Mahaffey KW, et al. Efficacy and safety of enoxaparin compared with unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndrome undergoing percutaneous coronary intervention in the Superior Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors (SYNERGY) trial. Am Heart J 2006; 152: 1042–50. CrossRef
- Fifth Organization to Assess Strategies in Acute Ischemic Syndromes investigators. Comparison of fondaparinux and enoxaparin in acute coronary syndromes. N Engl J Med 2006; 354: 1464–76. CrossRef
- Lincoff AM, Bittl JA, Harrington RA, et al, for the REPLACE-2 investigators. Bivalirudin and provisional glycoprotein IIb/IIIa blockade compared with heparin and planned glycoprotein IIb/IIIa blockade during percutaneous coronary intervention: REPLACE-2 randomized trial. JAMA 2003; 289: 853–63. CrossRef
- Stone GW, Witzenbichler B, Guagliumi G, et al. HORIZONS-AMI Trial Investigators. Bivalirudin during primary PCI in acute myocardial infarction. N Engl J Med 2008;358:2218–30. CrossRef
- Kim MH, Yu LH, Tanaka H, Mitsudo K. Experience with a novel retrograde wiring technique for coronary chronic total occlusion. J Interv Cardiol 2013;26(3):254–8. CrossRef
- Muramatsu T. Current technical and clinical features of the antegrade and retrograde approaches to percutaneous transluminal coronary intervention for chronic total occlusion-2013 version. Syllabus of TOPIC meeting 2013. p179.
- Sharman S, Patel S, Behl A, et al. Extensive Fatal Intracoronary Thrombosis During Percutaneous Coronary Intervention With Bivalirudin. Am J Ther 2013 Jul 25 [Epub ahead of print].
- Stone GW, McLaurin BT, Cox DA, et al, for the ACUITY investigators. Bivalirudin for patients with acute coronary syndromes. N Engl J Med 2006; 355: 2203–16. CrossRef
- Dangas GD, Mehran R, Nikolsky E, et al. Effect of switching anti-thrombotic agents for primary angioplasty in acute myocardial infarction. The HORIZONS-SWITCH analysis. J Am Coll Cardiol 2011;57:2309–2316. CrossRef
- Koutouzis M, Lagerqvist B, James S, et al. Unfractionated heparin administration in patients treated with bivalirudin during primary percutaneous coronary intervention is associated lower mortality and target lesion thrombosis: a report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). Heart 2011;97 (18):1484–8. CrossRef
- Langrish JP, Fox KAA. Optimal antithrombotic treatment during primary percutaneous coronary intervention? Heart 2011;97:1459–60. CrossRef
- Shahzad A, Cooper RM, Stables RH. Anthithrombotic therapy in PCI: Why not heprin? Eurointervention 2013;22:423–6. CrossRef
- Opposition: Unfractionated heparin should no longer be used in the catheterization laboratory
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ASEAN Heart Journal
- Online Date
- May 2014
- Online ISSN
- ASEAN Federation of Cardiology
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