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…