Home Treatment & Recovery Clot Busters

Clot Busters - Other Medications Used with Clot Busters

Overview

Heart attack patients treated with clot busters are also given anticoagulants ( blood thinners) and antiplatelets (drugs that make the blood less sticky) to help prevent further clots from developing, and to help prevent clots that have developed from getting bigger.

Heparin

Heparin is an anticoagulant that is given through an intravenous (IV) line in the arm during treatment with some clot busters (alteplase and reteplase). Because heparin affects the blood’s ability to clot, it can lead to bleeding problems. In early studies that combined clot busters and heparin, there were high rates of bleeding problems and stroke. Physicians now use lower doses of heparin to reduce this risk.

Low Molecular Weight Heparin

Finding the right dose of heparin for each patient is tricky; hospital staff must run blood tests and make dose adjustments if necessary. A newer type of heparin called low molecular weight heparin (LMWH) does not require such close monitoring. It is also easier to administer: LMWH is injected under the skin twice a day whereas regular heparin is given through an IV line in the arm. LMWH may be substituted for regular heparin in some heart attack patients treated with clot busters. One study showed that patients treated with LMWH and clot busters were less likely to die, suffer a heart attack or angina than those treated with regular heparin. However, there was no significant difference between the two treatments in women.21 There was also a tendency for people treated with LMWH to have more bleeding problems than those treated with regular heparin. This was especially true for patients older than 75 years.22

Aspirin & Antiplatelets

Antiplatelet medications make the blood less sticky, which helps prevent blood clots from forming. Aspirin is the most common antiplatelet. Studies show that the benefits of aspirin and clot busters appear to be additive. Combining the two medications reduces the chances of dying from a heart attack more than either aspirin or clot busters alone.23

Super Aspirins

Other antiplatelets include glycoprotein (GP) IIb/IIIa inhibitors. These medications are the so-called “super aspirins” because they work in a similar way to aspirin but have a much stronger effect. Abciximab (pronounced ab-six-i-mab) is one example of a super aspirin.

The combination of clot busters and super aspirins may be used in certain heart attack patients. Research studies suggest that while this combination is faster at restoring blood flow to the heart, this does not seem to lower the risk of dying after a heart attack.24 This combined therapy also seems to be riskier than clot busters alone. Patients treated with both drugs have a higher risk of bleeding complications and they are more likely to develop a dangerously low blood cell count than patients treated with clot busters alone. 25, 26 The increased bleeding risk seems to be confined to patients older than 75 years so combined therapy is usually avoided in older patients.

Direct Antithrombins

Direct antithrombins are a type of anticoagulant. They may be substituted for regular heparin in heart attack patients who experience an allergic reaction to heparin. Otherwise, direct thrombin inhibitors are not generally given to heart attack patients. Studies show that combining bivalirudin with clot busters reduces the risk of subsequent heart attack compared with regular heparin. However, this benefit is outweighed by a significant increase in bleeding problems.27

References


1. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Lancet. 1994;343:311-322.
2. Angeja BG, Rundle AC, Gurwitz JH, Gore JM, Barron HV. Death or nonfatal stroke in patients with acute myocardial infarction treated with tissue plasminogen activator. Participants in the National Registry of Myocardial Infarction 2. Am J Cardiol. 2001;87:627-630, A629.
3. Woodfield SL, Lundergan CF, Reiner JS, et al. Gender and acute myocardial infarction: is there a different response to thrombolysis? J Am Coll Cardiol. 1997;29:35-42.
4. Weaver WD, White HD, Wilcox RG, et al. Comparisons of characteristics and outcomes among women and men with acute myocardial infarction treated with thrombolytic therapy. GUSTO-I investigators. JAMA. 1996;275:777-782.
5. Gore JM, Granger CB, Simoons ML, et al. Stroke After Thrombolysis : Mortality and Functional Outcomes in the GUSTO-I Trial. Circulation. 1995;92:2811-2818.
6. Gurwitz JH, Gore JM, Goldberg RJ, et al. Risk for Intracranial Hemorrhage after Tissue Plasminogen Activator Treatment for Acute Myocardial Infarction. Ann Intern Med. 1998;129:597-604.
7. Brass LM, Lichtman JH, Wang Y, et al. Intracranial Hemorrhage Associated With Thrombolytic Therapy for Elderly Patients With Acute Myocardial Infarction : Results From the Cooperative Cardiovascular Project. Stroke. 2000;31:1802-1811.
8. Karnash SL, Granger CB, White HD, et al. Treating menstruating women with thrombolytic therapy: insights from the global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries (GUSTO-I) trial. J Am Coll Cardiol. 1995;26:1651-1656.
9. White HD, Barbash GI, Modan M, et al. After correcting for worse baseline characteristics, women treated with thrombolytic therapy for acute myocardial infarction have the same mortality and morbidity as men except for a higher incidence of hemorrhagic stroke. The Investigators of the International Tissue Plasminogen Activator/Streptokinase Mortality Study. Circulation. 1993;88:2097-2103.
10. Angeja BG, Alexander JH, Chin R, et al. Safety of the weight-adjusted dosing regimen of tenecteplase in the ASSENT-Trial. Am J Cardiol. 2001;88:1240-1245.
11. Van de Werf F, Barron HV, Armstrong PW, et al. Incidence and predictors of bleeding events after fibrinolytic therapy with fibrin-specific agents: a comparison of TNK-tPA and rt-PA. Eur Heart J. 2001;22:2253-2261.
12. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004;Available at www.acc.org/clinical/guidelines/stemi/index.pdf.
13. Barron HV, Bowlby LJ, Breen T, et al. Use of reperfusion therapy for acute myocardial infarction in the United States: data from the National Registry of Myocardial Infarction 2. Circulation. 1998;97:1150-1156.
14. Canto JG, Allison JJ, Kiefe CI, et al. Relation of Race and Sex to the Use of Reperfusion Therapy in Medicare Beneficiaries with Acute Myocardial Infarction. N Engl J Med. 2000;342:1094-1100.
15. Maynard C, Weaver WD, Lambrew C, et al. Factors influencing the time to administration of thrombolytic therapy with recombinant tissue plasminogen activator (data from the National Registry of Myocardial Infarction). Participants in the National Registry of Myocardial Infarction. Am J Cardiol. 1995;76:548-552.
16. Lambrew CT, Bowlby LJ, Rogers WJ, Chandra NC, Weaver WD. Factors influencing the time to thrombolysis in acute myocardial infarction. Time to Thrombolysis Substudy of the National Registry of Myocardial Infarction-1. Arch Intern Med. 1997;157:2577-2582.
17. Gan SC, Beaver SK, Houck PM, et al. Treatment of acute myocardial infarction and 30-day mortality among women and men. N Engl J Med. 2000;343:8-15.
18. Ayanian JZ, Hauptman PJ, Guadagnoli E, et al. Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med. 1994;331:1136-1142.
19. Goldberg RJ, Steg PG, Sadiq I, et al. Extent of, and factors associated with, delay to hospital presentation in patients with acute coronary disease (the GRACE registry). Am J Cardiol. 2002;89:791-796.
20. Mosca L, Jones WK, King KB, et al. Awareness, perception, and knowledge of heart disease risk and prevention among women in the United States. American Heart Association Women's Heart Disease and Stroke Campaign Task Force. Arch Fam Med. 2000;9:506-515.
21. Ross AM, Molhoek P, Lundergan C, et al. Randomized comparison of enoxaparin, a low-molecular-weight heparin, with unfractionated heparin adjunctive to recombinant tissue plasminogen activator thrombolysis and aspirin: second trial of Heparin and Aspirin Reperfusion Therapy (HART II). Circulation. 2001;104:648-652.
22. Wong GC, Giugliano RP, Antman EM. Use of low-molecular-weight heparins in the management of acute coronary artery syndromes and percutaneous coronary intervention. JAMA. 2003;289:331-342.
23. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet. 1988;2:349-360.
24. Verheugt FW. GUSTO V: the bottom line of fibrinolytic reperfusion therapy. Lancet. 2001;357:1898-1899.
25. Topol EJ. Reperfusion therapy for acute myocardial infarction with fibrinolytic therapy or combination reduced fibrinolytic therapy and platelet glycoprotein IIb/IIIa inhibition: the GUSTO V randomised trial. Lancet. 2001;357:1905-1914.
26. Van der Werf F, Armstrong, P.W., Granger, C. et al. Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: the ASSENT-3 randomised trial in acute myocardial infarction. Lancet. 2001;358:605-613.
27. White H. Thrombin-specific anticoagulation with bivalirudin versus heparin in patients receiving fibrinolytic therapy for acute myocardial infarction: the HERO-2 randomised trial. Lancet. 2001;358:1855-1863.


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