RESUMO
BACKGROUND: This study was designed to analyze the impact of treatment with either unfractionated heparin or enoxaparin (low molecular weight heparin) on plasma markers of thrombotic and endogenous thrombolytic activity in patients with non-ST segment elevation acute coronary syndromes. METHODS: A subset of 174 patients derived from the 3,171 patients of the ESSENCE study was evaluated. Eighty-seven patients were assigned to intravenous unfractionated heparin (target aPTT: 55-85 sec) (group UH), and 87 assigned to subcutaneous enoxaparin (1 mg/kg/q12hr) (group ENOX) for a minimum of 48 hours of treatment (average duration of treatment 88+/-45 hours). The thrombin time, and plasma levels of anti-factor Xa activity, prothrombin fragment F 1+2, thrombin-antithrombin complex (TAT), and D-dimer, were assayed at baseline, and at or close to peak activity 24-36 hrs, and at 72-90 hrs for those remaining on treatment with antithrombotic therapy. Major ischemic and hemorrhagic events were assessed throughout hospitalization. The levels of the thrombotic markers measured at or close to peak activity at 36 hours are presented below, and compared to clinical outcome at 30 days. RESULTS: In UH patients, the thrombin time increased 7 fold while the mean value for anti-Xa activity was 0.27 IU/ml; in ENOX patients the thrombin time increased 2.3 fold, and the mean value for anti-Xa activity was 0.83 IU/ml. In UH pts, basal levels of F 1+2, TAT, and D-dimer declined by (deltapaired) -0.8, -3. 3, and -66, respectively. In ENOX pts, basal levels of F 1+2, TAT, and D-dimer declined by (deltapaired) -0.3, -4.7, and -23, respectively. No significant differences were observed between the paired differences in thrombotic markers (UH vs ENOX), nor in the rate of recurrent ischemic events or major hemorrhage. CONCLUSIONS: In this subset of patients enrolled in the ESSENCE study, enoxaparin 1 mg/kg ql2hr significantly increased anti-Xa activity above that seen with unfractionated heparin, and reduced thrombin production without prolonging the thrombin time. The high anti-Xa activity achieved with enoxaparin was not associated with a loss of safety.
Assuntos
Doença das Coronárias/tratamento farmacológico , Enoxaparina/uso terapêutico , Fibrinolíticos/uso terapêutico , Heparina/uso terapêutico , Biomarcadores , Doença das Coronárias/fisiopatologia , Método Duplo-Cego , Eletrocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome , Resultado do TratamentoRESUMO
OBJECTIVES: Evidence exists showing an association between Chlamydial infection and infarction. Our purpose was to identify an interactive relationship between Chlamydia pneumoniae and unstable angina. METHODS: We analyzed IgG antibodies for Chlamydia pneumoniae, Mycoplasma pneumoniae, and C reactive protein in patients during the acute phase of unstable angina. RESULTS: Chlamydia antibodies were present in 16.92% (11 cases) of the unstable angina patients. They were also present in 34.61% of those patients who experienced ischemic events vs 5.1% who did not (odds ratio 9.79, 95% CL 1.65 to 75.26, p = 0.002). Mycoplasma pneumoniae antibodies were present in 12.30% of patients but did not emerge as a predictive variable. C-reactive protein was present in 22 cases (33.84%), 9 of which were associated with recurrent events (34.61%) vs 13 which were free of them (odds ratio, p = 0.5). The interactive relationship between infection plus C-reactive protein achieved a statistical significant association with ischemic events (odds ratio 14, 95% CI 1.49-331.1; p = 0.003). CONCLUSIONS: These findings suggest a pathophysiologically based relationship between infective and inflammatory processes related to poor clinical outcome during the in-hospital stay in the setting of unstable angina patients.
Assuntos
Angina Instável/sangue , Antígenos de Bactérias/sangue , Proteína C-Reativa/análise , Infecções por Chlamydia/imunologia , Chlamydophila pneumoniae/imunologia , Imunoglobulina G/sangue , Mycoplasma pneumoniae/imunologia , Pneumonia por Mycoplasma/imunologia , Angina Instável/imunologia , Angina Instável/microbiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/etiologia , PrognósticoRESUMO
OBJECTIVES: This study was designed to test the hypothesis that low molecular weight heparin may lessen the severity of ischemic events in patients with unstable angina. BACKGROUND: Unstable angina is a thrombotic process that requires intensive medical treatment. Although current treatments can reduce the number of complications, serious bleeding continues to occur. Nadroparin calcium, a low molecular weight heparin, seems to be a safe therapeutic agent that does not require laboratory monitoring. METHODS: A total of 219 patients with unstable angina entered the study at a mean time of 6.17 h after the last episode of rest pain. Patients were randomized to receive aspirin (200 mg/day [group A]), aspirin plus regular heparin (400 IU/kg body weight per day intravenously and titered by activated partial thromboplastin time [group B]) and aspirin plus low molecular weight heparin (214 UIC/kg anti-Xa twice daily subcutaneously [group C]). The major end points determined for the in-hospital period were 1) recurrent angina, 2) myocardial infarction, 3) urgent revascularization, 4) major bleeding, and 5) death. Minor end points were 1) silent myocardial ischemia, and 2) minor bleeding. Event rates were tested by chi-square analysis. RESULTS: Recurrent angina occurred in 37%, 44% and 21% of patients in groups A, B and C, respectively, and was significantly less frequent in group C than in either group A (odds ratio 2.26, 95% confidence interval [CI] 1 to 5.18, p = 0.03) or group B (odds ratio, 3.07, 95% CI 1.36 to 7.00, p = 0.002). Nonfatal myocardial infarction was present in seven patients in group A, four in group B and none in group C (group B vs. A, p = 0.5; group C vs. A, p = 0.01). Urgent revascularization was performed in nine patients in group A, seven in group B and one in group C (C vs. A, p = 0.01). Two episodes of major bleeding occurred in group B. Silent myocardial ischemia was present in 38%, 41% and 25% of patients in groups A, B and C, respectively, and was significantly less frequent in group C than group B (odds ratio 2.12, 95% CI 0.97 to 4.69, p = 0.04). Minor bleeding was detected in 10 patients in group B, 1 patient in group C (B vs. C, p = 0.01) and no patient in group A (A vs. B, p = 0.003). CONCLUSIONS: In this study, treatment with aspirin plus a high dose of low molecular weight heparin during the acute phase of unstable angina was significantly better than treatment with aspirin alone or aspirin plus regular heparin.
Assuntos
Angina Instável/tratamento farmacológico , Aspirina/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Heparina/uso terapêutico , Isquemia Miocárdica/tratamento farmacológico , Adulto , Idoso , Angina Instável/prevenção & controle , Aspirina/efeitos adversos , Distribuição de Qui-Quadrado , Quimioterapia Combinada , Feminino , Hemorragia/induzido quimicamente , Heparina/efeitos adversos , Heparina de Baixo Peso Molecular/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/prevenção & controle , Isquemia Miocárdica/prevenção & controle , Razão de Chances , Estudos Prospectivos , Recidiva , Método Simples-Cego , Resultado do TratamentoRESUMO
The purpose of this study was to determine whether computerized ST-segment monitoring previous to percutaneous transluminal coronary angioplasty (PTCA) and after performance of this procedure may be useful to discern a pattern of recurrent angina. For this purpose, we analyzed 57 patients (11 women and 46 men, mean age 60 years) before and after treatment with balloon procedure. These patients were followed up during the next 3 months. A computerized electrocardiographic (ECG) device was used which was capable of recording simultaneously all 12 leads at rest. It was programmed to store a complete ECG every 5 min and was capable of detecting any abnormal ST alteration > than 0.5 mV at 80 ms after J junction, including R-wave amplitude. Measurements were started before (mean time 7.26 h) and after (mean time 7.96 h) the procedure. The value for ST amplitude at the J junction was used as the 0 point; then the most negative depression or the most positive elevation value was considered as the most abnormal ST alteration during monitoring. The patients were followed up for 3 months for the purpose of recognizing recurrent angina or establishing the occurrence of death. Twelve patients (30%) had recurrent angina. Discriminant function analysis revealed that ST monitoring in these patients showed significant difference after PTCA in comparison with controls, both in the frontal plane [ST depression 170 +/- 52 mV vs. 231 +/- 23 (p = 0.02)] and in precordial leads [176 +/- 16 vs. 80 +/- 6.19 mV (p = 0.0001)].(ABSTRACT TRUNCATED AT 250 WORDS)