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With tenecteplase, enoxaparin, a 30 mg intravenous bolus, followed by 1 mg/kg every 12 hours, resulted in a lower incidence of the composite of death, myocardial infarction, refractory ischemia, and disabling stroke in the ASSENT-3 trial, but bleeding rates were increased in the elderly In the larger EXTRACT trial, enoxaparin reduced death and myocardial infarction at day 30 (compared with unfractionated heparin), at the expense of a modest increase in bleeding In patients younger than age 75, enoxaparin was given as a 30 mg intravenous bolus and 1 mg/kg every 12 hours; in patients age 75 years and older, it was given with no bolus and 075 mg/kg intravenously every 12 hours Another antithrombotic option is fondaparinux, given at a dose of 25 mg subcutaneously once a day In the OASIS-6 trial, it resulted in significant reductions in death and reinfarction when compared with control (unfractionated heparin when indicated, otherwise placebo) Similar to the findings of the OASIS-5 trial, fondaparinux tended to result in less bleeding, despite its longer duration compared with heparin and despite its comparison to placebo in about half of the enrolled patients There was no benefit of fondaparinux among patients undergoing primary PCI, and fondaparinux is not recommended as a sole anticoagulant during PCI due to risk of catheter thrombosis For all patients with acute myocardial infarction treated with intensive antithrombotic therapy, prophylactic treatment with antacids and an H2-blocker is advisable Myocardial reperfusion can be recognized clinically by the early cessation of pain and the resolution of ST-segment elevation Although at least 50 70% resolution of ST-segment elevation by 90 minutes may occur without coronary reperfusion, ST resolution is a strong predictor of better outcome Even with anticoagulation, 10 20% of reperfused vessels will reocclude during hospitalization, although reocclusion and reinfarction appear to be reduced following intervention Reinfarction, indicated by recurrence of pain and ST-segment elevation, can be treated by readministration of a thrombolytic agent or immediate angiography and PCI The role of catheterization and intervention after thrombolysis is controversial For patients who do not reperfuse based on lack of at least 50% resolution of ST elevation, rescue angioplasty has been shown to reduce the composite of death, reinfarction, stroke, or severe heart failure Many cardiologists advocate routine catheterization and revascularization following acute myocardial infarction, in otherwise suitable candidates, although the data to support this are inconclusive Patients with recurrent ischemic pain prior to discharge should undergo catheterization and, if indicated, revascularization Asymptomatic, clinically stable patients should undergo predischarge evaluation to determine whether residual jeopardized myocardium is present This can be accomplished by submaximal exercise or pharmacologic stress scintigraphy Those with significantly positive tests or a low threshold for symptomatic ischemia should undergo angiography and revascularization where feasible.

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