Excess enoxaparin increases adverse outcomes in non-ST elevation ACS


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

Bottom Line:
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]

Study Design:
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)

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