Fondaparinux in Pulmonary Embolism
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《新英格兰医药杂志》
To the Editor: The Matisse Investigators (Oct. 30 issue)1 conclude that fondaparinux is as effective as intravenous unfractionated heparin in the treatment of hemodynamically stable pulmonary embolism. The authors state that "care was taken to apply the highest treatment standards to the use of unfractionated heparin." Heparin infusions were adjusted to maintain the activated partial-thromboplastin time at a value that was 1.5 to 2.5 times the control value. Modern thromboplastin reagents are more sensitive than the older reagents that were used to determine this traditional therapeutic range. Suboptimal dosing will occur if this activated partial-thromboplastin time ratio is used as the therapeutic range.2 The American College of Chest Physicians and the College of American Pathologists recommend that the therapeutic range of the activated partial-thromboplastin time for each reagent–instrument system be determined by the comparison of ex vivo specimens with the use of a validated heparin assay, such as one based on anti-factor Xa.3,4 Using the activated partial-thromboplastin time ratio to determine the therapeutic range with respect to heparin administration is no longer the standard of practice and, in the reported study, could have affected the primary outcome of recurrent thromboembolic events.
References
The Matisse Investigators. Subcutaneous fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism. N Engl J Med 2003;349:1695-1702. [Abstract/Full Text]
Raschke R, Hirsh J, Guidry JR. Suboptimal monitoring and dosing of unfractionated heparin in comparative studies with low-molecular-weight heparin. Ann Intern Med 2003;138:720-723. [Abstract/Full Text]
Hyers TM, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease. Chest 2001;119:Suppl:176S-193S. [Full Text]
Olson JD, Arkin CF, Brandt JT, et al. College of American Pathologists Conference XXXI on laboratory monitoring of anticoagulant therapy: laboratory monitoring of unfractionated heparin therapy. Arch Pathol Lab Med 1998;122:782-798. [ISI][Medline](James Wertz, Pharm.D.)
References
The Matisse Investigators. Subcutaneous fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism. N Engl J Med 2003;349:1695-1702. [Abstract/Full Text]
Raschke R, Hirsh J, Guidry JR. Suboptimal monitoring and dosing of unfractionated heparin in comparative studies with low-molecular-weight heparin. Ann Intern Med 2003;138:720-723. [Abstract/Full Text]
Hyers TM, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease. Chest 2001;119:Suppl:176S-193S. [Full Text]
Olson JD, Arkin CF, Brandt JT, et al. College of American Pathologists Conference XXXI on laboratory monitoring of anticoagulant therapy: laboratory monitoring of unfractionated heparin therapy. Arch Pathol Lab Med 1998;122:782-798. [ISI][Medline](James Wertz, Pharm.D.)