p.26 抽出テキスト

CLINICAL STATEMENTS AND GUIDELINES

April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e796

(Bleeding Academic Research Consortium) types 3-5 bleeding (4.39% versus 3.06%; P =0.007).15 All-cause death was also reduced with bivalirudin (3.92% versus 2.96%; P =0.04), as well as 30-day stent thrombosis (0.37% versus 1.1%; P =0.0015). Based on these results, when bivalirudin is used to support PPCI for STEMI, a postprocedure 2- to 4-hour infusion at full dose is recommended.15,38,39

6 Meta-analyses comparing bivalirudin versus UFH

with or without glycoprotein IIb/IIIa inhibitors in patients with ACS demonstrate that bivalirudin is associated with a lower risk for major bleeding.16,17,40 In the context of NSTE-ACS, bivalirudin was evaluated in the ACUITY (A Comparison of Angiomax Versus Heparin in Acute Coronary Syndromes) trial, where bivalirudin was noninferior to UFH plus glycoprotein IIb/IIIa inhibitor for the risk of MACE and superior with respect to 30-day major bleeding.41 The bleeding definition used in the study was specific to the ACUITY trial. Bivalirudin was also evaluated in the MATRIX (Minimizing Adverse Hemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX) trial where it was compared against UFH alone (ie, without concomitant glycoprotein IIb/IIIa inhibitor).42 No significant difference was observed between the 2 arms with respect to 30-day ischemic or bleeding events. 7.	 Intravenous enoxaparin compared with UFH

reduces the risk for ischemic outcomes without a significant difference in bleeding in the setting of PPCI. In the ATOLL (Acute Myocardial Infarction Treated with Primary Angioplasty and Intravenous Enoxaparin or Unfractionated Heparin to Lower Ischemic and Bleeding Events at Short- and Longterm Follow-up) trial,24 which enrolled patients presenting with STEMI, the primary endpoint of 30-day incidence of death, complication of MI, procedural failure, or major bleeding occurred in 28% of patients with enoxaparin compared with 34% with UFH (P =0.06). Although the incidence of primary endpoint was not significantly different between enoxaparin and UFH, the secondary endpoint of 30-day death, recurrent ACS, or urgent revascularization was significantly lower in the enoxaparin group (7% versus 11%; P =0.015). In addition, a net clinical benefit (death, complication of MI, or major bleeding) was observed with enoxaparin compared with UFH (10% versus 15%; P =0.03). In a meta-analysis of 10 451 patients, intravenous enoxaparin was associated with a significant reduction in death and major bleeding.26

8 Fondaparinux should not be used as the sole antico-

agulant to support PCI because of the risk of catheter thrombosis.5,27,31 In the OASIS-5 trial, an increase was observed in the rate of catheter-related thrombus with fondaparinux compared with enoxaparin (0.9% versus 0.4%).5 Similar results were observed in the OASIS-6 (The Safety and Efficacy of Fondaparinux versus Control Therapy in Patients with STEMI) trial in which a higher rate of guiding-catheter thrombosis and more coronary complications with fondaparinux were observed when used during PCI.27

9 In patients with STEMI treated with fibrinolytic

therapy, parenteral anticoagulation is recommended before and after fibrinolytic therapy to reduce ischemic events. In studies of fibrinolytic therapy such as the GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) trial, the ASSENT-3 (Assessment of the Safety and Efficacy of a New Thrombolytic Regimen) trial, or the ExTRACT-TIMI 25 (Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment- Thrombolysis in Myocardial Infarction 25) study, intravenous heparin was administered for at least 48 hours.10,29,43 In the ExTRACT-TIMI 25 study, the UFH infusion was given for at least 48 hours but could be continued for a longer period at the treating physician’s discretion, whereas the subcutaneous injections of enoxaparin were continued until hospital discharge or for a maximum of 8 days (whichever came first).10 Patients randomized to enoxaparin had a lower risk of death or nonfatal recurrent MI through 30 days compared with UFH (9.9% versus 12.0%); however, treatment with enoxaparin was associated with an increase in major bleeding (2.1% versus 1.4%).10

10 In patients with STEMI who received fibrinolytic

therapy and who are not planned for an invasive approach, enoxaparin is the preferred anticoagulant over UFH.9,10,28,29,44 In the ExTRACT-TIMI 25 study, enoxaparin until hospital discharge or for a maximum of 8 days (whichever came first) was compared with UFH administered for at least 48 hours (could be continued for a longer period at the treating physician’s discretion) in 20 506 patients with STEMI receiving fibrinolytic therapy.10 The primary endpoint of death or nonfatal recurrent MI through 30 days occurred in 12% in the UFH group compared with 9.9% in the enoxaparin group. In a meta-analysis of 14 randomized trials, UFH did not reduce reinfarction or death in patients treated with fibrinolytic therapy. In contrast, low-molecularweight heparin reduced the risk of reinfarction and death compared with placebo and the risk of reinfarction.45

11 In patients with STEMI who are not likely to undergo

an invasive approach, fondaparinux is an alternate anticoagulant that can be used. In the OASIS-6 trial of patients with STEMI who were treated with thrombolytic agents (predominantly streptokinase),

Downloaded from http://ahajournals.org by on October 7, 2026