Suboptimal anticoagulation with pre-hospital heparin in ST-elevation myocardial infarction
This is a prospective, observational study performed in all consecutive ST-elevation myocardial infarction (STEMI) patients who had activated clotting time (ACT) measurement on arrival in the cathlab before coronary angiography. We studied the therapeutic effects of a pre-hospital fixed heparin bolus dose in consecutive patients with STEMI. A total of 1,533 patients received pre-hospital administration of aspirin, high dose clopidogrel (600 mg) and a fixed bolus dose of 5,000 IU unfractionated heparin (UFH), according to the national ambulance protocols. Some patients were also treated with glycoprotein IIb/IIIa inhibitors (GPI) in the ambulance. A therapeutic ACT range was defined according to the ESC guidelines as 200-250 seconds when patients had GPI pretreatment and 250-350 seconds when no GPI pre-treatment. Of the 1,533 patients, 216 patients (14.1%) had an ACT within the therapeutic range, 82.3% of the patients had a too low ACT, whereas 3.5% of the patients had a too high ACT. After multivariable analysis, the only independent predictor of a too low ACT was increasing weight (odds ratio 1.02/kg, 95% confidence interval 1.01-1.03, p=0.001). Patients with a too low ACT had less often an open infarct related vessel (initial TIMI flow 2,3) as compared to patients with an ACT in range (36.5% vs. 45.9%, p=0.013). In only a minority of patients with STEMI, pre-hospital treatment with a fixed bolus dose UFH is within the therapeutic ACT range. Increased weight is an independent determinant of a too low ACT. We strongly recommend weight adjusted administration of UFH in the ambulance.
|Keywords||Activated clotting time, Fixed bolus dose, Primary percutaneous coronary intervention, ST-elevation myocardial infarction, Unfractionated heparin|
|Persistent URL||dx.doi.org/10.1160/TH11-04-0257, hdl.handle.net/1765/33823|
Hermanides, R.S., Ottervanger, J.P., Dambrink, J.-H.E., de Boer, M.-J., Hoorntje, J.C.A., Marcel Gosselink, A.T., … van't Hof, A.W.J.. (2011). Suboptimal anticoagulation with pre-hospital heparin in ST-elevation myocardial infarction. Thrombosis and Haemostasis: international journal for vascular biology and medicine, 106(4), 636–640. doi:10.1160/TH11-04-0257