Minimal Heparinization in Coronary Angioplasty—How Much Heparin Is Really Warranted? Edo Kaluski, MD, Ricardo Krakover, MD, Gad Cotter, MD, Alberto Hendler, MD, Itzhak Zyssman, MD, Olga Milovanov, MD, Alex Blatt, MD, Ester Zimmerman, RN, Edna Goldstein, RN, Vera Nahman, RN, and Zvi Vered, MD The purpose of the study was to assess the results of percutaneous transluminal coronary angioplasty (PTCA), performed with a single intravenous bolus of 2,500 U of heparin, in a nonemergency PTCA cohort. Three hun- dred of 341 consecutive patients (87.9%) undergoing PTCA were prospectively enrolled in the study. They received heparin, 2,500-U intravenous bolus, before PTCA, with intention of no additional heparin adminis- tration. Patient and lesion characteristics as well as PTCA results were evaluated independently by 2 physicians. Patients were followed up by structured telephone ques- tionnaires at 1 and 6 months after PTCA. Mean activated clotting time obtained 5 minutes after heparin adminis- tration was 185  19 seconds (range 157 to 238). There were 3 (1%) in-hospital major adverse cardiovascular events: 2 deaths (0.66%), 1 (0.33%) Q-wave myocardial infarction. Emergency coronary surgery and stroke were not reported. Six patients (2%) experienced abrupt cor- onary occlusion within 14 days after PTCA, warranting repeat target vessel revascularization. Angiographic and clinical success were achieved in 96% and 93.3%, respectively. No bleeding or vascular complications were recorded. Six-month follow-up (184 patients) re- vealed 3 cardiac deaths (1 arrhythmic, 2 after cardiac surgery), 1 Q-wave myocardial infarction, and 9.7% repeat target vessel revascularization. This study sug- gests that very low doses of heparin and reduced acti- vated clotting time target values are safe in non-emer- gency PTCA, and can reduce bleeding complications, hospital stay, and costs. Larger, randomized, double- blind heparin dose optimization studies need to confirm this notion. 2000 by Excerpta Medica, Inc. (Am J Cardiol 2000;85:953–956) H igh-dose heparin to sustain the activated clotting time (ACT) 300 seconds became a mandatory percutaneous transluminal coronary angioplasty (PTCA) routine after 3 retrospective studies 1–3 concluded that less intense anticoagulation protocols may yield a higher incidence of abrupt vessel closure and ischemic complications. A subsequent publication 4 was not able to confirm the inverse relation or association between ACT levels and abrupt vessel closure in elective PTCA. More recent publications 5 have reported the safety of low-dose heparin (5,000 U) during elective coronary interventions in conjunction with abbrevi- ated post-PTCA monitoring period (limited to 4 hours). 6 Vainer et al 7 compared the safety and efficacy of 5,000 U of heparin with 20,000 U of heparin in a nonselective PTCA cohort. They concluded that low- dose heparin resulted in somewhat better angiographic success (p 0.05), and significantly less vascular and bleeding complications (p 0.0001). We elected to take heparin dosage 1 step further: a pilot study pro- spectively assessing the short- and long-term safety and efficacy of minidose heparin (2,500 U) in a non- emergency PTCA cohort. METHODS Patient selection: Between February and June 1998 (subsequent to local and national ethics committee approval) 300 of 341 consecutive patients (87.9%) undergoing PTCA were prospectively enrolled in the protocol. Patients were excluded for the following reasons: primary or rescue PTCA in acute myocardial infarctions (22 patients), planned rotational atherecto- mies (8 patients), physician’s preference (5 patients), and cardiogenic shock or intra-aortic balloon insertion not in the setting of acute myocardial infarction (6 patients). Ninety-three percent were ad hoc PTCAs, whereas only 7% were previously planned procedures. PTCA procedure: All enrolled patients received 2,500 U of unfractionated heparin before guiding catheter insertion with the intention of administering no additional heparin. Additional heparin was at the discretion of the operator. The interventionalists were blinded to the ACT results (obtained by Hemochron 801), monitored 5 minutes after heparin administra- tion. Six or 7Fr femoral sheaths and guiding catheters were used in conjunction with rapid exchange coro- nary balloons and stents. Contrast agent was uni- formly nonionic Iopromide (Ultravist 370 by Scher- ing). Femoral sheaths were removed as early as “hold- ing area” staff was ready, and within 2 hours after PTCA. It was our intention to monitor our patients for 3 hours after PTCA, and discharge them from the hospital within 18 hours if clinically feasible and appropriate. Before discharge, a cardiologist evaluated From the Assaf Harofeh Cardiology Institute, Zerifin, Israel. Manuscript received August 27, 1999; revised manuscript received and ac- cepted November 9, 1999. Address for reprints: Edo Kaluski, MD, Assaf Harofeh Medical Center, Zerifin, D.N. Beer Yacov, 70300, Israel. E-mail: ekaluski@ asaf.health.gov.il. 953 ©2000 by Excerpta Medica, Inc. All rights reserved. 0002-9149/00/$–see front matter The American Journal of Cardiology Vol. 85 April 15, 2000 PII S0002-9149(99)00908-X