Heparin v LMWH for STEMI with PCI

13 Nov

Montalescot, Gilles, Uwe Zeymer, Johanne Silvain, Bertrand Boulanger, Marc Cohen, Patrick Goldstein, Patrick Ecollan, et al “Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: the international randomised open-label ATOLL trial..” Lancet 378, no. 9792 (August 20, 2011): 693–703. PMID 21856483

As the NNT points out we don’t really know if heparin is of much use in ACS. These authors even point out:

the European Society of Cardiology continue to afford unfractionated heparin a class 1 recommendation for this indication while recognising that evidence is limited (level of evidence C).

So the whole thing is a bit of a mess. Which these guys try to clarify a bit.


  • Sanofi funded trial
  • RCT open label of PCI STEMIs to either LMWH or heparin IV
  • outcome was the usual nonsense composite of death and hangnails (as per Jerry Hoffmann…)


  • n = 910
  • LMWH was better on every level when you look at the numbers
  • in terms of important things it was 4% v 6% for death (note low death rate overall) but not big enough numbers to prove anything that effective (ie statistical significance)
  • even bleeding was less for LMWH
  • I don’t think the conclusions in the abstract are that fair (they don’t mention that the trial was negative for primary outcome for example) but there still seems to be a small benefit there

I would much prefer to see an appropriately powered trial for mortality with a placebo arm. But then I’d like a golden toilet seat and I don’t see that happening either…

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