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Pretreatment With Unfractionated Heparin in ST-Elevation Myocardial Infarction—A Propensity Score Matching Analysis
Sascha Macherey-Meyer1, Sebastian Heyne, Max Maria Meertens
1University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine; Cardiology III - Angiology, Department of Cardiology, University Hospital of Johannes Gutenberg University, Mainz; Department of Emergency Medicine, Leverkusen Hospital, Leverkusen; Department of Cardiology and Internal Intensive Care Medicine, Augustinian Hospital, Academic Teaching Hospital, Cologne; Department of Medicine and Cardio-Diabetes Center Cologne, St. Antonius Hospital, Cologne; Department of Cardiology and Internal Intensive Care Medicine, Cologne-Kalk Protestant Hospital, Cologne; Department of Cardiology, Electrophysiology, and Rhythmology, Porz on Rhine Hospital, Cologne; Department of Internal Medicine III - Cardiology, St. Vincent Hospital, Cologne; Department of Medicine II, Merheim Hospital, Cologne Municipal Hospital Group, Cologne; Institute for Medical Statistics and Bioinformatics, Faculty of Medicine and University Hospital, University of Cologne.
Insights
Unfractionated heparin (UFH) pretreatment before primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) did not significantly improve outcomes or increase bleeding risk. Individual risk-benefit assessment is advised due to a lack of high-quality trial evidence.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Research
Background:
- Patients with ST-segment elevation myocardial infarction (STEMI) often receive unfractionated heparin (UFH) pretreatment before primary percutaneous coronary intervention (PPCI).
- The clinical benefit and safety of UFH pretreatment remain debated due to conflicting study findings.
- This study retrospectively analyzes registry data to evaluate UFH pretreatment risks and benefits in STEMI patients undergoing PPCI.
Purpose of the Study:
- To assess the safety and efficacy of unfractionated heparin (UFH) pretreatment in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI).
- To compare key clinical outcomes, including infarct-related artery patency, in-hospital mortality, and access-site bleeding, between STEMI patients with and without UFH pretreatment.
Main Methods:
- Retrospective analysis of registry data from 4632 STEMI patients undergoing PPCI between 2005 and 2020.
- Propensity score matching (PSM) was used to adjust for confounding factors, comparing 511 pretreated patients with 187 non-pretreated patients.
- Key endpoints analyzed included infarct-related artery (IRA) patency, in-hospital mortality, access-site bleeding, and peak creatine kinase (CK) levels.
Main Results:
- UFH pretreatment was administered to 95.4% of STEMI patients.
- After PSM, UFH pretreatment was not significantly associated with improved IRA patency (OR 1.01 [0.59; 1.74]), reduced in-hospital mortality (OR 1.46 [0.88; 2.42]), or increased access-site bleeding (OR 0.59 [0.14; 2.46]).
- Peak creatine kinase levels were similar between the UFH pretreated and non-pretreated groups.
Conclusions:
- Unfractionated heparin (UFH) pretreatment in STEMI patients undergoing PPCI was not linked to significant improvements in major clinical outcomes or increased bleeding risk.
- UFH pretreatment was less common in patients who had undergone cardiopulmonary resuscitation.
- Given the lack of high-quality trial evidence, the decision for UFH pretreatment should be individualized, considering alternative antithrombotic strategies.
Background:
Patients with ST-segment elevation myocardial infarction (STEMI) are often pretreated with unfractionated heparin (UFH) before a primary percutaneous coronary intervention (PPCI). UFH pretreatment is intended to lessen the thrombotic burden, but there have been conflicting study findings on its safety and efficacy. We assessed the risks and benefits of UFH pretreatment with a retrospective analysis of registry data from the STEMI network of a German metropolitan region.
Methods:
Data from patients with STEMI referred for PPCI from 2005 to 2020 were evaluated with an adjusted outcome analysis, including propensity score matching (PSM). The endpoints included the patency of the infarct-related artery (IRA) after PPCI, in-hospital mortality, access-site bleeding, and the peak creatine kinase (CK) level.
Results:
We assessed data from 4632 patients with STEMI: 4420 (95.4%) were pretreated with UFH, and 212 (4.6%) were not. After PSM of 511 vs. 187 patients, the adjusted odds ratios for the various endpoints were (pretreatment vs. no pretreatment, with 95% confidence intervals): for impaired flow of the IRA, 1.01 [0.59; 1.74]; for in-hospital mortality, 1.46 [0.88; 2.42]; and for access-site bleeding, 0.59 [0.14; 2.46]. The peak creatine kinase levels were similar in the two groups (median, 1248.0 vs. 1376.5 U/L, estimated difference -134 [-611; 341]).
Conclusion:
UFH pretreatment was less frequently performed in STEMI patients who had undergone cardiopulmonary resuscitation. UFH pretreatment was not associated with increased access-site bleeding, nor was it found to have significantly higher efficacy with respect to the relevant endpoints. The risks and benefits of UFH pretreatment should be weighed individually in each case, as evidence from high-quality clinical trials is lacking. Data from the existing literature suggest that no pretreatment is an option to be considered, as are certain alternative antithrombotic strategies.
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