Patients with acute coronary syndromes (ACS) may transition to percutaneous coronary intervention (PCI) after an initial phase of medical management that includes anticoagulation. When patients come to the catheterization laboratory, it is important to consider previously received anticoagulation. Enoxaparin has emerged as a more effective, yet simple, agent for use in the emergency room or upon initial encounter of the ACS patient. However, there may be uncertainty among physicians on the adequacy and way to use anticoagulation in the transition to the catheterization laboratory. Recently, new data have emerged on the use of enoxaparin in the catheterization laboratory. Dosing schedules based on pharmacodynamic and clinical data offer a seamless transition for enoxaparin from the medical management phase to PCI. In this paper, the pharmacokinetics of enoxaparin are reviewed and recommendations for anticoagulant regimens provided based upon the timing of presentation and pre-catheterization dosing.

In this issue of the Journal, Drs. El-Atat, Sharma and colleagues present the first pilot study in the United States to evaluate the clinical outcomes of patients with aspirin resistance who were assigned to either double versus triple antiplatelet therapy undergoing elective percutaneous coronary intervention (PCI). Although their numbers are small, the results suggest that patients with aspirin resistance had improved clinical outcomes if a glycoprotein IIb/IIIa inhibitor was added to the standard dual-antiplatelet regimen.

This study adds to the growing body of evidence that suggests, “One size does not fit all” when it comes to optimal pharmacological platelet inhibition for PCI. Why, with about one million PCIs performed each year in the United States, is there such a paucity of data to guide how we inhibit platelets both acutely and long term in patients who undergo coronary stent implantation? We would like to suggest that there are several reasons — all of which need to be addressed in order for us to optimize patient care. These reasons can be categorized as measurement or definition inconsistencies, pharmacologic and drug interaction issues, clinical event disconnections and perhaps patient-related issues of compliance and/or non-uniform variability.

ABSTRACT: Background. The prevalence of diabetes mellitus (DM) and ischemic heart disease is increasing. Moreover, patients with DM experiencing an acute coronary syndrome (ACS) have an increased risk of adverse outcomes after revascularization compared to non-diabetics.