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To the Editor: Dr Alexander and colleagues¹ studied excess dosing of antithrombotic therapy in patients with non–ST-segment elevation acute coronary syndromes. We support their conclusions that this occurs frequently and is associated with major bleeding. However, it is possible that the finding of a nonsignificant adjusted odds ratio for any excess dose of unfractionated heparin (1.08; 95% confidence interval, 0.94-1.26), which was also lower than that for other antithrombotic agents, was primarily related to the inherent difficulty in defining an excess dose regimen.

Because of its highly variable pharmacokinetics and anticoagulant effect, the optimal dose of unfractionated heparin requires careful adjustments according to the activated partial thromboplastin time (aPTT) instead of body weight.² A weight-based cutoff may not accurately differentiate among patients administered appropriate, excess, or inadequate doses of unfractionated heparin. Furthermore, despite strict adherence to dose titration nomograms in clinical trials, substantial fluctuations in aPTT are common within the . . . [Full Text of this Article]

Andrew T. Yan, MD; Raymond T. Yan, MD; Shaun G. Goodman, MD, MSc
goodmans@smh.toronto.on.ca
St Michael's Hospital
University of Toronto
Toronto, Ontario

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