The low molecular weight heparin enoxaparin is commonly used in the management of patients with non-ST segment elevation acute coronary syndromes (ACS). It is perceived that there is variable acceptance of the use of enoxaparin in patients with ACS in conjunction with percutaneous coronary intervention (PCI) by Canadian interventional cardiologists, as well as diverse approaches to the procedural (ie, PCI) management of anticoagulation.
A survey assessing physician and centre demographics, as well as the opinion and approach to the use of enoxaparin in patients undergoing PCI, was developed. All 141 interventional cardiologists performing PCI in Canada were sent the survey, with a 52% response rate. The majority (64%) of respondents were comfortable performing PCI during enoxaparin treatment, but almost one-half (46.5%) stated a preference to have a point-of-care measurement of the anticoagulation level during the procedure. Various 'top-up' protocols are used across the country, including fixed-dose intravenous (IV) enoxaparin, weight-adjusted IV enoxaparin, fixed-dose IV unfractionated heparin, weight-adjusted IV unfractionated heparin and IV unfractionated heparin titrated to a target activated clotting time. Although the median time threshold for administering a 'top-up' dose of anticoagulation matched current recommendations, there was a wide variation ranging from 2 h to 10 h (median 8 h).
Although the majority of Canadian interventional cardiologists were comfortable performing PCI in patients treated with enoxaparin, the survey demonstrated various levels of confidence and a diverse range of 'top-up' anticoagulation procedures. Nationwide guidelines for the management of anticoagulation in patients with ACS undergoing PCI with enoxaparin should be developed from the best available clinical and research evidence to limit potential patient risk of inadequate or excessive anticoagulation. This is especially relevant in view of the association between switching among anticoagulant therapies and an increased bleeding risk in patients undergoing early cardiac catheterization and PCI that was found in the recently reported Superior Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors (SYNERGY) trial.