Due UFH along with enoxaparin.4 Because only certain

Due to the risk of
catheter thrombosis, fondaparinux should not be used alone for a patient
undergoing primary percutaneous coronary intervention during acute coronary
syndrome (ACS).1 The 2013 ACCF/AHA guidelines made this
recommendation according to the results of the OASIS-6 trial, which showed an
increase in the rates of guiding catheter thrombus when fondaparinux was used
without unfractionated heparin (UFH).2 Several trials have been
conducted to test the safety and efficacy of fondaparinux compared to other
anticoagulant medications for early invasive management strategies of ACS.

In the OASIS-5 trial,
enoxaparin and fondaparinux were compared for the primary efficacy outcome of death,
myocardial infarction (MI), or refractory ischemia at nine days in patients
with ACS with non-ST segment elevation (NSTEMI).3 While fondaparinux
proved to be statistically insignificant in the trial’s primary outcomes, the
drug was superior clinically at reducing the rate of death as well as the
amount of bleeding when compared to enoxaparin. The trial stated that reasons
for increased bleeding in enoxaparin are not known, but may be correlated to
the high dose that was used.3 With the results of this study, fondaparinux
appeared to be the drug of choice for PCI patients for short term treatment. However,
the occurrence of catheter thrombus was still higher in patients who were on
fondaparinux versus those who were on enoxaparin.4 In a
prospectively planned analysis of the OASIS-5 trial, it was concluded that the
lower incidence of thrombi occurrence in those on enoxaparin may have been
associated with the use of UFH along with enoxaparin.4 Because only
certain endpoints were evaluated, the recommendation of using fondaparinux in
intervention therapy was not established through the conclusion of this trial.

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Further investigation
into the use of fondaparinux was conducted in the OASIS-6 trial with patients
who had ST-segment elevation myocardial infarction.2 Compared to
patients who were on either placebo or UFH, patients who were on fondaparinux
had a reduced composite of death and myocardial infarction 9 days and 30 days
after the PCI was performed.2 The study showed that fondaparinux was
a better treatment plan compared to usual care as it reduced death,
reoccurrence of MI, and cardiac tamponade all without increasing the chance of
bleeding or stroke.2 A prospective cohort study that was conducted
in Sweden concluded that in patients with NSTEMI, fondaparinux was more
advantageous at reducing major bleeding events and death up to 180 days after
initial use when compared to low molecular weight heparin.5 These
results are consistent with the OASIS-5 trial.2 When fondaparinux
was used as the sole anticoagulant agent, the rate of thrombi formation was increased
compared to other drugs as it is a factor Xa inhibitor only. This allows factor
IIa to still develop clots; therefore, adding a factor IIa inhibitor such as
UFH improves drug therapy.2 In terms of catheter thrombosis.
patients who were treated with UFH had low incidences of experiencing
complications.2 Comparatively, patients who were treated with
fondaparinux prior to receiving a PCI and was then given UFH also experienced a
low rate of catheter thrombosis.2 This confirmed that fondaparinux
used in combination with UFH for patients undergoing intervention therapy is
safe and effective. This combination therapy seems to be the most beneficial as
it reduces mortality and morbidity risk in PCI patients. The correct dosage of UFH
was later determined in the FUTURA/OASIS-8 randomized trial.7

European Society of Cardiology has a class IB recommendation on the use of
fondaparinux with UFH in NSTEMI PCI patients.6 Like the ACCF/AHA
guidelines, the safest recommendation for patients undergoing PCI is
bivalirudin combination therapy as an alternative to UFH.6 The
recommendation that fondaparinux should not be used as a sole agent to treat
ACS patients who will undergo PCI is consistent in all guidelines.1.6
Based off the evidence and data provided, I would agree with the recommendation.


I'm Alfred!

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