Minimal heparinization in coronary angioplasty—how much heparin is really warranted?

doi:10.1016/S0002-9149(99)00908-X

The American Journal of Cardiology

Volume 85, Issue 8, 15 April 2000, Pages 953-956

https://doi.org/10.1016/S0002-9149(99)00908-X Get rights and content

Abstract

The purpose of the study was to assess the results of percutaneous transluminal coronary angioplasty (PTCA), performed with a single intravenous bolus of 2,500 U of heparin, in a nonemergency PTCA cohort. Three hundred of 341 consecutive patients (87.9%) undergoing PTCA were prospectively enrolled in the study. They received heparin, 2,500-U intravenous bolus, before PTCA, with intention of no additional heparin administration. Patient and lesion characteristics as well as PTCA results were evaluated independently by 2 physicians. Patients were followed up by structured telephone questionnaires at 1 and 6 months after PTCA. Mean activated clotting time obtained 5 minutes after heparin administration was 185 ± 19 seconds (range 157 to 238). There were 3 (1%) in-hospital major adverse cardiovascular events: 2 deaths (0.66%), 1 (0.33%) Q-wave myocardial infarction. Emergency coronary surgery and stroke were not reported. Six patients (2%) experienced abrupt coronary occlusion within 14 days after PTCA, warranting repeat target vessel revascularization. Angiographic and clinical success were achieved in 96% and 93.3%, respectively. No bleeding or vascular complications were recorded. Six-month follow-up (184 patients) revealed 3 cardiac deaths (1 arrhythmic, 2 after cardiac surgery), 1 Q-wave myocardial infarction, and 9.7% repeat target vessel revascularization. This study suggests that very low doses of heparin and reduced activated clotting time target values are safe in non-emergency PTCA, and can reduce bleeding complications, hospital stay, and costs. Larger, randomized, double-blind heparin dose optimization studies need to confirm this notion.

Section snippets

Patient selection

Between February and June 1998 (subsequent to local and national ethics committee approval) 300 of 341 consecutive patients (87.9%) undergoing PTCA were prospectively enrolled in the protocol. Patients were excluded for the following reasons: primary or rescue PTCA in acute myocardial infarctions (22 patients), planned rotational atherectomies (8 patients), physician’s preference (5 patients), and cardiogenic shock or intra-aortic balloon insertion not in the setting of acute myocardial

Patient characteristics (Table I)

Fifty-six and 6/10% of patients had unstable or postinfarction angina, 40.3% of patients had recent myocardial infarction (occurring <14 days before PTCA), and 11.3% had clinical congestive heart failure on current admission.

Lesion characteristics

Target lesion distribution according to the American Heart Association/American College of Cardiology classification was: type A 7%, type B1 30.3%, type B2 51.6%, and type C 11%. Mean lesion length was 8.3 ± 7.8 mm.

Target vessel distribution

The target PTCA vessel was left anterior descending in

Discussion

This is the first study to use 2,500 U heparin in a nonselective PTCA cohort (excluding only emergency PTCAs and cardiogenic shock). Most patients had acute coronary syndromes. Sixty-two percent of the lesions were either type B2 or C.

The study protocol was closely followed. Only 4% of the enrolled patients received additional heparin boluses, and not even a single patient was subject to prolonged heparin administration, or any other method of prolonged anticoagulation. Only 16% received

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