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(Circulation. 2004;110:392-398.)
© 2004 American Heart Association, Inc.

Original Articles

Anti-Xa Activity Relates to Survival and Efficacy in Unselected Acute Coronary Syndrome Patients Treated With Enoxaparin

G. Montalescot, MD, PhD; J.P. Collet, MD, PhD; M.L. Tanguy, MD; A. Ankri, MD; L. Payot, MD; R. Dumaine, MD; R. Choussat, MD; F. Beygui, MD; V. Gallois, BS; D. Thomas, MD

From the Institut de Cardiologie (G.M., J.P.C., L.P., R.D., R.C., F.B., V.G., D.T.), Department of Biostatistics (M.L.T.), and Hemostasis Laboratory (A.A.), Pitié-Salpêtrière Hospital, Paris, France.

Correspondence to Dr G. Montalescot, Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière (AP-HP), 47, boulevard de l’Hôpital, 75013 Paris, France. E-mail gilles.montalescot{at}psl.ap-hop-paris.fr

Received November 14, 2003; de novo received March 13, 2004; revision received April 29, 2004; accepted April 30, 2004.

Background— Low-molecular-weight heparin (LMWH) is recommended in the treatment of unstable angina (UA)/non–ST-segment–elevation myocardial infarction (NSTEMI), but no relationship has ever been shown between anticoagulation levels obtained with LMWH treatment and clinical outcomes.

Methods and Results— In all, 803 consecutive patients with UA/NSTEMI were treated with subcutaneous enoxaparin and were followed up for 30 days. The recommended dose of enoxaparin of 1 mg/kg BID was used throughout the population except when physicians decided on dose reduction because of a history of a recent bleeding event or because of a high bleeding risk. Anti–factor Xa activity was >0.5 IU/mL in 93% of patients; subtherapeutic anti-Xa levels (<0.5 IU/mL) were associated with lower doses of enoxaparin. The 30-day mortality rate was significantly associated with low anti-Xa levels (<0.5 IU/mL), with a >3-fold increase in mortality compared with the patients with anti-Xa levels in the target range of 0.5 to 1.2 IU/mL (P=0.004). Multivariate analysis revealed low anti-Xa activity as an independent predictor of 30-day mortality at least as strong as age, left ventricular function, and renal function. In contrast, anti-Xa activity did not predict major bleeding complications within the range of anti-Xa levels observed in this study.

Conclusions— In this large unselected cohort of patients with UA/NSTEMI patients, low anti-Xa activity on enoxaparin treatment is independently associated with 30-day mortality, which highlights the need for achieving at least the minimum prescribed anti-Xa level of 0.5 IU/mL with enoxaparin whenever possible.

Key Words: enoxaparin • myocardial infarction • acute coronary syndrome

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