Optimal activated clotting time during percutaneous coronary intervention.
نویسندگان
چکیده
Percutaneous Coronary Intervention To the Editor: We read with interest the article by Chew et al1 in the February 20, 2001, issue of Circulation, but we were disappointed that such eminent investigators could confuse associations arising from heterogeneous pooled data with hard evidence on which scientific conclusions can be drawn. In their Conclusions, they state that their meta-analysis “. . .identifies an optimal level of ACT [activated clotting time] for patients undergoing PCI [percutaneous coronary intervention] in the range of 350 to 375 s.” Their data, however, merely show that when aiming for an ACT of 300 to 350 s, an ACT of ,300 s or .475 s is a marker for increased events. It is quite possible that the level of anticoagulation has nothing to do with the increase in events. Our conclusions from these data were that a high ACT after standard-dose heparin most likely reflects low body weight, a well-recognized cause of increased events.2 Logistic regression may have helped clarify the relative importance of low body weight versus ACT in determining events in this group. Similarly, a low ACT with a standard heparin dose (heparin resistance) is a marker of systemic acute-phase response and would be associated with more actively inflamed plaques and thus a higher acute event rate, independent of anticoagulation level. Only 85% of patients had an ACT measured, and it was ,300 s in .50% of subjects. Measurement and maintenance of ACT were obviously not an important part of the study protocols. Also, non-target ACTs may have been associated with poor operators and related complications. There was also marked heterogeneity of the patient populations and heparin protocols in the different trials. The composite end points varied from 10.8% in the Evaluation of Platelet IIb/IIIa Inhibitor for Stenting (EPISTENT) study3 to 17.8% in the ReoPro and Primary PTCA Organization and Randomized Trial (RAPPORT).4 Major bleeding rates also varied significantly, from 2.2% in EPISTENT3 to 9.5% in RAPPORT.4 Because the heparin regimens varied from fixed bolus2 to weight-adjusted bolus with titration3 with or without postprocedural infusion,3,5 it is possible that non-target ACTs may have been more prevalent in trials with higher event rates. Any correlation between ACT and end points should have been adjusted in a multivariate manner for the trial. In their Discussion, the authors mentioned that data from well-designed, prospective, randomized trials have contradicted the conclusions of this meta-analysis. Because of the difficulty with confounding variables, nonprospective data pooling must be regarded as inferior evidence to these trials, irrespective of the numbers involved, and cannot support changes in clinical practice.
منابع مشابه
Defining the optimal activated clotting time during percutaneous coronary intervention: aggregate results from 6 randomized, controlled trials.
BACKGROUND Unfractionated heparin has been the primary anticoagulant therapy for percutaneous coronary intervention for >20 years. Despite the availability of rapid "point of care" testing, little clinical data defining the optimal level of anticoagulation are available. Furthermore, recent reports have advocated the use of low-dose heparin regimens in the absence of large-scale, well-conducted...
متن کاملDefining the optimal activated clotting times during percutaneous coronary intervention: aggregate results from 6 randomized, controlled trials.
During Percutaneous Coronary Intervention: Aggregate Results From 6 Randomized, Controlled Trials To the Editor: A recent article in Circulation by Chew et al1 stated that the optimal range of activated clotting time (ACT) for unfractionated heparin therapy in percutaneous coronary interventions (PCI) is between 350 and 375 seconds. These data have been obtained by a post hoc analysis from 6 ra...
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INTRODUCTION Percutaneous coronary intervention (PCI) may be associated with Thrombotic complications. Unfractionated heparin (UFH) is a potent and preferable antithrombotic agent during this procedure. Activated clotting time (ACT) is a good assay for accurate titration of UFH during PCI. The aim of this study was to evaluate ACT levels 10 minutes after administration of 100U/kg IV heparin and...
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عنوان ژورنال:
- Circulation
دوره 104 15 شماره
صفحات -
تاریخ انتشار 2001