Anticoagulant therapy is a major component in the management of
acute coronary syndromes (ACS). Four
anticoagulant agents are currently commercially available for ACS, namely
unfractionated heparin (UFH),
enoxaparin,
bivalirudin and
fondaparinux. We describe the advantages of
fondaparinux and the reasons that have hampered its uptake into routine management of ACS.
Fondaparinux was shown to be efficacious in the prevention of
deep vein thrombosis vs low-molecular-weight heparins, while in the setting of venous thrombo-embolic disease, it was shown to be noninferior to
enoxaparin and UFH. Two pivotal studies have demonstrated the efficacy of
fondaparinux as an
anticoagulant in the setting of ACS, namely OASIS-5 in non-ST elevation ACS, and OASIS-6 in
ST elevation myocardial infarction (MI). In OASIS-5,
fondaparinux was shown to be noninferior to
enoxaparin in terms of death, MI or refractory
ischemia at 9 days. Furthermore, a 50% reduction in
bleeding complications was obtained with
fondaparinux vs
enoxaparin, leading to a risk reduction for death. In OASIS-6,
fondaparinux was shown to be superior to the comparator (UFH or placebo). European and North American guidelines give
fondaparinux a Grade 1A and 1B recommendation respectively, but uptake of
fondaparinux in routine practice has been slow. We explore reasons for this, such as prevailing doubts about the efficacy of
fondaparinux in the setting of angioplasty, the problem of
catheter thrombosis, and the lack of
antidote in case of
bleeding complications. With the exception of primary angioplasty,
fondaparinux is as effective as
enoxaparin or UFH, but is also associated with a considerable reduction in
bleeding complications, and thus, an undeniable net clinical benefit.