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Long-term management--the way forward?
1Department of Cardiology, University Hospital, Uppsala, Sweden. lars.wallentin@card.uas.lul.se
Insights
Low-molecular-weight heparins like dalteparin sodium may extend treatment for unstable coronary artery disease (UCAD). The FRISC II study found dalteparin sodium reduced cardiac events, acting as a bridge to revascularization.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Unstable coronary artery disease (UCAD) treatment typically involves aspirin, unfractionated heparin (UFH), beta blockers, and nitrates.
- Low-molecular-weight heparins (LMWHs) offer advantages over UFH, prompting investigation into extended treatment durations for UCAD patients.
Purpose of the Study:
- To evaluate the efficacy of prolonged treatment with the LMWH dalteparin sodium (Fragmin) in patients with UCAD.
- To assess dalteparin sodium's role as a bridge to revascularization procedures.
Main Methods:
- The Fragmin and Fast Revascularization during InStability in Coronary artery disease (FRISC II) study utilized a factorial design.
- Patients were randomized to either an invasive or noninvasive management strategy and to dalteparin sodium or placebo treatment.
Main Results:
- Dalteparin sodium significantly reduced the incidence of death and/or myocardial infarction (MI) in the initial months.
- A significant reduction in the triple endpoint (death, MI, revascularization) was observed at 3 months with dalteparin sodium compared to placebo.
- The risk of new postprocedural events was low in both treatment arms for patients undergoing revascularization.
Conclusions:
- Dalteparin sodium demonstrates efficacy in reducing cardiac events during the acute phase and serves as a valuable bridge to revascularization in UCAD patients.
- Prolonged treatment with LMWHs like dalteparin sodium may be appropriate for managing unstable coronary artery disease.
Abstract:
The mainstay of treatment for unstable coronary artery disease (UCAD) currently consists of antithrombotic therapy with aspirin plus unfractionated heparin (UFH), together with anti-ischemic treatment with beta blockers and nitrates. Recently, there has been a trend toward replacement of UFH with low-molecular-weight heparins (LMWHs), since these products offer significant advantages over the parent compound. Several lines of evidence suggest that prolongation of treatment with LMWHs beyond the acute phase may be appropriate in patients with UCAD. The Fragmin and Fast Revascularization during InStability in Coronary artery disease (FRISC II) study was designed to evaluate this hypothesis using the LMWH dalteparin sodium (Fragmin). A factorial design was used to randomize patients enrolled in the FRISC II study to an invasive or noninvasive management strategy, and to treatment with dalteparin sodium or placebo. Treatment with dalteparin sodium significantly reduced incidences of death and/or myocardial infarction (MI) during the first months of treatment (the reduction in the relative risk of double endpoint events was statistically significant at 47.0% at 1 month, and remained so at 2 months, but was no longer statistically significant at the 3-month assessment). However, risk, as defined by the triple endpoint of death, MI, and revascularization, was significantly lower (13.0% relative risk reduction) at 3-month follow-up in the treatment group randomized to dalteparin sodium than among patients receiving placebo. In patients in whom revascularization procedures were carried out, the risk of new, postprocedural events was low in both the placebo and dalteparin sodium arms. Thus, dalteparin sodium appears to protect patients from cardiac events until they undergo invasive procedures, and it can therefore be used as a bridge to revascularization.