Low molecular weight heparins and glycoprotein IIb/IIIa antagonists

The consistent message that emerges from virtually every recent acute coronary syndrome (ACS) trial is that the old "standard" of using aspirin and unfractionated heparin (UFH) can be considerably improved upon. Low molecular weight heparins (LMWHs) (most notably enoxaparin) are emerging as a broad replacement for UFH. Initial safety concerns about combining LMWHs and glycoprotein (GP) IIb/IIIa antagonists have not been borne out; in fact, major bleeding complications may be lower with LMWHs. Clinical outcomes to date suggest that LMWHs may be a better first line therapy than UFH on which to superimpose adjunctive GP IIb/IIIa antagonists. Emerging clinical experience further supports the safety and efficacy of this combination regimen. The forthcoming SYNERGY study will prospectively compare enoxaparin and UFH in high risk patients in whom an invasive management strategy is pursued, with a high coincident use of GP IIb/IIIa antagonists. As the standard of care moves forward, we will see increasing use of LMWHs, with and without GP IIb/IIIa antagonists in conservatively and invasively managed patients.