Hartii

An argument also has been made for substituting an antithrombin more effective than heparin in combination with a fibrinolytic. Low molecular weight heparins (LMWHs) have theoretical advantages over unfractionated heparin (142). Unlike unfractionated heparin, LMWHs interact less with elements in the circulation (plasma proteins, platelets, leukocytes, endothelial cells), have more predictable kinetics, are effective inhibitors of thrombin generation (antifactor Xa activity) as well as thrombin generation (anti-IIa activity), are given in fixed doses without the requirement for monitoring, and have compared well with heparin in clinical trials (143).

The HART II trial was an angiographic trial of 400 patients with AMI given aspirin and accelerated tPA randomized to weight adjusted heparin or enoxaparin 30 mg IV then 1 mg/kg sc at 15 min and every 12 h (144). Coronary patency was greater with enoxaparin than heparin (80 vs 75%), and reocclusion rates were lower (6 vs 10%) without excessive bleeding.

Table 5

Mortality Trials with Combined Thrombolytic and GP IIb/IIIa Inhibitor Therapy

Table 5

Mortality Trials with Combined Thrombolytic and GP IIb/IIIa Inhibitor Therapy

Endpoints

GUSTO-VAMI (145)

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