Suboptimal anticoagulation with pre-hospital heparin in ST-elevation myocardial infarction

• Published in: Thrombosis and haemostasis Vol. 106; no. 4; p. 636
• Main Authors: Hermanides, Renicus S, Ottervanger, Jan Paul, Dambrink, Jan-Henk E, de Boer, Menko-Jan, Hoorntje, Jan C A, Gosselink, A T Marcel, Suryapranata, Harry, Zijlstra, Felix, van 't Hof, Arnoud W J
• Format: Journal Article
• Language: English
• Published: Germany 01-10-2011
• Subjects: Aged; Body Weight; Diagnostic Tests, Routine - methods; Drug Dosage Calculations; Electrocardiography; Emergency Medical Services; Female; Heparin - administration & dosage; Heparin - adverse effects; Humans; Male; Middle Aged; Myocardial Infarction - diagnosis; Myocardial Infarction - drug therapy; Myocardial Infarction - physiopathology; Practice Guidelines as Topic; Predictive Value of Tests; Prognosis; Prospective Studies; Whole Blood Coagulation Time
• ISSN: 0340-6245
• DOI: 10.1160/TH11-04-0257

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 pre-treatment 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.