Excess enoxaparin increases adverse outcomes in non-ST elevation ACS

What are the effects of excess and inadequate enoxaparin dosing on outcomes in patients with NSTE ACS?

Patients with NSTE ACS who receive higher than recommended doses of enoxaparin are at increased risk for major bleeding and in-hospital mortality. (LOE = 2b)

LaPointe NM, Chen AY, Alexander KP, et al. Enoxaparin dosing and associated risk of in-hospital bleeding and death in patients with non-ST-segment elevation acute coronary syndromes. Arch Intern Med 2007;167:1539-44.  [PMID:17646609]

Cohort (retrospective)

Industry + govt

Inpatient (any location)

Data from the CRUSADE registry (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines) were analyzed to determine the frequency of enoxaparin dosing that was in excess or lower than recommended (> 10 mg above or below the recommended dose) in patients with NSTE ACS and the associated risks of in-hospital major bleeding and mortality. Recommended enoxaparin dosing was 1 mg/kg every 12 hours or 1 mg/kg every 24 hours for patients with a creatinine clearance less than 30 mL/min. The cohort consisted of the 10,687 patients with NSTE ACS who had complete data. Of these patients, 18.7% received an excess dose of enoxaparin and 29.2% received a lower-than-recommended dose. Excess LMWH dosing compared to recommended dosing was associated with increased major bleeding [14.2% vs. 7.3%, number needed to harm (NNH) 15, 95% CI 11.6 - 19] and in-hospital mortality (5.6% vs. 2.4%, NNH 31, 95% CI 23 - 46). Inadequate dosing trended toward an increase in mortality (3,3% vs. 2.4%, p = 0.11)