Percutaneous of fondaparinux vs usual care or unfractionated

Percutaneous coronary intervention
(PCI) is a nonsurgical procedure that increase the amount of blood flow that
reaches the heart by reducing the narrowing of the artery. Patients who undergo
PCI introduce a foreign object into their body and require the use of anticoagulants.
Fondaparinux is a synthetic inhibitor of factor Xa and can treat and prevent
blood clots from forming. According to the 2013 ACCF/AHA guideline the use of
fondaparinux in patients undergoing PCI during acute coronary syndrome (ACS) is
not currently a recommendation for use.1

In the OASIS-5 trial two
anticoagulants, fondaparinux and enoxaparin, were compared to evaluate the
anti-ischemic benefits while still reducing the bleeding in PCI. The primary
outcome (death, myocardial infarction, or refractory ischemia) was
statistically similar in both medications.2 This means that the
efficacy of both drugs and their anti-ischemic benefits was similar. The
OASIS-5 trial also found that fondaparinux, compared to enoxaparin,
significantly reduced bleeding, and found that it decreased long-term mortality
and morbidity.2 The significance of this trial is that fondaparinux
is similar to enoxaparin in preventing ischemic events during PCI while also
substantially decreasing the bleeding. OASIS-5 does seem to support the use in
patients undergoing PCI during ACS but other trials will later contradict these
finding.

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The OASIS-6 trial studied the
effects of fondaparinux vs usual care or unfractionated heparin in patients
with STEMI. The primary outcome (composite of death or reinfarction at 30 days)
was significantly reduced in the fondaparinux group compare to usual care or
unfractionated heparin.3 OASIS-6 also found that fondaparinux did
not increase bleeding or hemorrhagic stroke.3 These two outcomes
provide statistical data that fondaparinux is superior in treatment in certain
cases for patients with ACS. However, there were findings in the OASIS-6 trial
in patients undergoing PCI that provided data that fondaparinux increased the
rates of coronary complications compared to heparin.3 The trial did
present that even though fondaparinux did have an increased rate of guiding
catheter thrombosis if PCI is done without pre-administer UFH, but with the UFH
used before the procedure the coronary complication can be avoided.3

A study was performed to evaluate
the overall analysis of patients undergoing PCI during ACS. This study
concluded similar findings of the OASIS-5 and OASIS-6 trial. It found that the
use of fondaparinux vs enoxaparin reduced bleeding while still providing
appropriate treatments.4 The study also determined that using UFH in
place of fondaparinux during PCI seemed to decrease catheter thrombus, without
potentially compromising the positive effects of fondaparinux.4
These two points are important to note because they are the reason that the use
on fondaparinux in PCI is being debated.

There are both advantages and
disadvantages to using fondaparinux in patients undergoing PCI. Many of the
trials and studies that are relevant to this subject provide data that could be
beneficial to the patient as well as harmful. The American College of
Cardiology Foundation and The American Heart Association Task Force on Practice
Guidelines are the experts who evaluate these risks and benefits of using
fondaparinux in PCI. The guideline took into consideration the findings in the
OASIS-6 trial that when using fondaparinux in PCI as the sole anticoagulant
there was an increased risk for angiographic complications that include
catheter thrombus. The guideline labeled using fondaparinux as the only
anticoagulant for PCI as a Class III: Harm because of the increased risk of
catheter thrombosis.1 Therefore, fondaparinux should not be used for
a patient undergoing PCI during ACS.

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