ISCHAEMIC HEART DISEASE

To use LMWH or not to use LMWH? ▸

In the UK at least, low molecular weight heparin (LMWH) rather than unfractionated heparin has become the standard of care in acute coronary syndromes (ACS). In the A phase of the A to Z trial, which involved nearly 4000 patients treated with aspirin and tirofiban, the primary end point (a seven day composite of death, myocardial infarction (MI), or refractory ischaemia) occurred in 8.4% of patients assigned to receive enoxaparin compared to 9.4% in those receiving unfractionated heparin (hazard ratio (HR) 0.88, 95% confidence interval (CI) 0.71 to 1.08). SYNERGY looked at the use of LMWH versus conventional heparin in more than 10000 patients whose ACS was also treated with an early invasive strategy. Their primary end point (30 day composite of death or MI) occurred in 14.0% of patients assigned to enoxaparin versus 14.5% receiving conventional heparin (HR 0.96, 95% CI 0.86 to 1.06). Again, the authors’ summary stated that enoxaparin was not inferior to unfractionated heparin, but neither was it superior. The meta-analysis by Peterson and colleagues included these two studies, the primary data from the ESSENCE trail, and the event frequencies derived from the TIMI 11B, ACUTE II, and INTERACT studies—thus data from over 22 000 patients were included. From these aggregate figures the authors conclude that enoxaparin is superior at preventing the 30 day occurrence of death or MI (odds ratio (OR) 0.81, or 0.91 if antithrombin treatment was given pre-randomisation).

Are statins safe to start in childhood? ▸

Atheroma begins in childhood as fatty streaks. Statins arrest, and may regress, atheroma, so why not start early? To investigate this further, Weigman and colleagues investigated the effect of 20–40 mg pravastatin in 214 children aged 8–18 years with familial hypercholesterolaemia who were treated continuously for two years. The efficacy of treatment was confirmed by lower values of low density lipoprotein (LDL) cholesterol and regression …