Non-ST-segment elevation acute coronary syndrome in patients with renal dysfunction:: benefit of low-molecular-weight heparin alone or with glycoprotein IIb/IIIa inhibitors on outcomes.: The Global Registry of Acute Coronary Events

Aims To determine whether low-molecular-weight heparin (LMWH)+glycoprotein (GP) IIb/IIIa inhibitors provide greater benefit than unfractionated heparin (UFH)+GP IIb/IIIa inhibitors, irrespective of renal status. Methods and results Patients in the Global Registry of Acute Coronary Events (GRACE) were divided into three groups according to creatinine clearance (CrCl): normal renal function (CrCl > 60 mL/min), moderate renal dysfunction (30 < CrCl <= 60 mL/min), and severe (CrCl <= 30 mL/min) renal dysfunction. Data were analysed from 11 881 patients with acute coronary syndrome (ACS). Patients with moderate (n=3705) or severe (n=982) renal dysfunction were at higher risk of adverse outcomes than those with normal renal function. Decreasing CrCl was an independent predictor of mortality at 30 days and in-hospital major bleeding. LMWH+GP IIb/IIIa inhibitors were used significantly less frequently in patients with severe (2.0%) or moderate (3.1%) renal dysfunction than in those with normal function (3.9%, P=0.0056). LMWH alone was more beneficial than UFH alone, irrespective of renal status. LMWH alone was an independent predictor of 30 day survival [odds ratio (OR) 0.56; 95% confidence interval (CI) 0.43-0.73] and lower risk of in-hospital bleeding (OR 0.66; 95% CI 0.48-0.92). Bleeding rates were significantly lower with LMWH+GP IIb/IIIa inhibitors than those with UFH+GP IIb/IIIa inhibitors. Use of UFH+GP IIb/IIIa inhibitors was an independent predictor of bleeding (OR 2.02; 95% CI 1.42-2.90) compared with UFH alone. Conclusion In patients with renal dysfunction and non-ST-segment elevation ACS, bleeding complications are more frequent and outcomes appear worse in individuals treated with UFH compared with LMWH. Combination therapy with LMWH and GP IIb/IIIa inhibitors appears to be better tolerated than with UFH and GP IIb/IIIa inhibitors.