Table 4
Author, date, and countryPatient groupStudy type (level of evidence)OutcomesKey resultsStudy weaknesses
CK-MB = creatine kinase MB fraction; IHD = ischaemic heart disease; LMWH = low molecular weight heparin; PRCT = prospective randomised controlled trial.
Gurfinkel et al, 1996, Argentina1219 patients with unstable anginaDouble blind PRCTMajor end points (recurrent angina, myocardial infarction, urgent revascular- isation, major bleeding, death)Recurrent angina, myocardial infarction, and urgent revascularisation were significantly less frequent in the LMWH group. Major bleeding only occurred in the unfractionated heparin group
Aspirin alone v aspirin and heparin v aspirin and LMWHMinor end points (silent myocardial ischaemia, minor bleeding)Silent myocardial ischaemia was significantly less frequent in the LMWH group. Minor bleeding was significantly more frequent in the unfractionated heparin group
Cohenet al, 1997 and 1998, USA2 33171 patients with angina at rest or non-Q wave myocardial infarctionDouble blind PRCTComposite end point (recurrent angina, myocardial infarction, death)No difference at 48 h. Significantly better (16.6% v 19.8%) in enoxaparin group at 14 days. Difference continues at 30 days
Enoxaparin v unfractionated heparin
PRISM Study Investigators, 1998, Multinational43232 with unstable angina, myocardial ischaemia, raised CK-MB or history of significant IHD. All on aspirinDouble blind PRCTComposite end point (refractory ischaemia, myocardial infarction, death)Significantly better (2.3% v 3.6%) in tirofiban group at 48h. No difference at 14 and 30 days, although mortality was lower in tirofiban group at this time. No difference in mortality at 6 months
Unfractionated heparin or tirofiban
PRISM-PLUS Study Investigators, 1998, Multinational51915 patients with unstable angina, myocardial ischaemia or raised CK-MB Double blind PRCTComposite end point (refractory ischaemia, myocardial infarction, death)Significantly worse mortality in tirofiban alone group at 7 days (4.6% v 1.1% for heparin alone)Tirofiban alone group stopped prematurely
All on aspirin
Unfractionated heparin or tirofiban or unfractionated heparin and tirofibanSignificantly lower composite end point occurrence in tirofiban plus heparin group at 7 (12.9% v 17.9%) and 30 days
The PARAGON Investigators, 1998, Multinational62282 patients with non-ST elevation acute coronary syndromes. All on aspirinDouble blind PRCTComposite end point (non-lethal myo- cardial infarction or death)No differences at 30 days. Significantly lower composite end point occurrence at 6 months for low dose lamifiban and heparin
High or low dose tirofiban with or without unfractionated heparin v heparin alone