The time dependence of antithrombin initiation in patients with non-ST-segment elevation acute coronary syndromes:
Deborah B Diercks1, Charles V Pollack, Judd E Hollander
1University of California, Davis Medical Center, Sacramento, CA, USA. dbdiercks@ucdavis.edu
Insights
Delays in antithrombin treatment for acute coronary syndromes did not increase ischemic events but did raise bleeding risks. Prompt administration is crucial to minimize adverse outcomes in these cardiac patients.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- Antithrombins are standard care for non-ST-segment elevation acute coronary syndromes (NSTE-ACS).
- Timely administration of these agents is critical for patient outcomes.
- The relationship between treatment delay and adverse events in NSTE-ACS requires further investigation.
Purpose of the Study:
- To investigate the association between the time to antithrombin administration and adverse cardiac events.
- To evaluate the impact of delayed treatment on ischemic events and bleeding complications in NSTE-ACS patients.
Main Methods:
- Analysis of a subgroup from the ACUITY trial, including patients with moderate- to high-risk NSTE-ACS undergoing early invasive strategy.
- Evaluation of time from emergency department (ED) presentation to antithrombin initiation (unfractionated heparin, low-molecular-weight heparin, or bivalirudin).
- Logistic regression used to adjust for patient demographics, disease severity, comorbidities, and treatment differences.
Main Results:
- No association was found between longer time to antithrombin treatment and major ischemic events (adjusted OR 0.99; 95% CI 0.97 to 1.01).
- Increased risk of major bleeding at 30 days and inhospital major bleeding complications was observed with longer treatment times (adjusted ORs 1.44 and 1.43, respectively).
- Median time to antithrombin administration was 4.87 hours.
Conclusions:
- Timing of antithrombin administration did not correlate with adverse ischemic outcomes in NSTE-ACS patients undergoing early invasive management.
- Increased time to antithrombin initiation was associated with a higher risk of bleeding complications.
- These findings highlight the importance of timely antithrombin therapy to mitigate bleeding risks in NSTE-ACS.
Study Objective:
Antithrombins are among standard treatment agents for patients with non-ST-segment elevation acute coronary syndromes. We aimed to determine the association between time from emergency department (ED) presentation to treatment with an antithrombin and adverse cardiac events.
Methods:
The study cohort was a subgroup of the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial, enrolled from March 1, 2005, to December 5, 2005. The ACUITY trial enrolled patients with moderate- and high-risk non-ST-segment elevation acute coronary syndromes and who were undergoing an early invasive strategy (<72 hours from randomization). All patients received an antithrombin (unfractionated heparin, low-molecular-weight heparin, or bivalirudin), in addition to other agents. A formal ED case report form was introduced in March 2005. Time from presentation to antithrombin initiation was evaluated as a continuous variable in hours. The endpoints were defined as major ischemic events (death, myocardial infarction, unplanned revascularization) or major bleeding within 30 days, or inhospital major bleeding. Logistic regression was used to adjust for demographics, severity of disease, comorbidities, and treatment differences.
Results:
Of the 2,722 patients enrolled with an ED case report form, complete time data were available in 2,632 (96%). Median time to antithrombin administration was 4.87 hours (interquartile range 2.67 to 9.83). After multivariable analysis, there was no association of major ischemic events with log time (hours) to antithrombin treatment (adjusted odds ratio [OR] 0.99; 95% confidence interval [CI] 0.97 to 1.01). There was an increase in major bleeding at 30 days and inhospital major bleeding complications with longer log time (hours) to antithrombin initiation (adjusted OR 1.44, 95% CI 1.15 to 1.80; OR 1.43, 95% CI 1.13 to 1.83, respectively).
Conclusion:
In this study of patients with non-ST-segment elevation acute coronary syndromes who were undergoing an early invasive management strategy, we were unable to demonstrate an association between adverse ischemic outcomes with the timing of antithrombin administration. However, there was an increase in bleeding outcomes as time to antithrombin administration increased.
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