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In Reply: Dr Goodman and colleagues raise the issue of variable pharmacokinetics for unfractionated heparin. We agree that defining excessive dosing of unfractionated heparin is a challenge on several fronts, and accordingly set the cutpoints for excess unfractionated heparin purposefully high. In terms of an association between excess unfractionated heparin and bleeding events, it is likely that clinician adjustment of heparin dose based on aPTT results ameliorated the relationship between the initial dose and bleeding.

Regarding the question of the influence of early catheter interventions in the setting of excess dosing, our population had a high rate of invasive care overall (>75% received a cardiac catheterization). Excess dosing was associated with higher rates of bleeding among patients who underwent early cardiac catheterization (11.9% vs 5.9%, P<.001) as well as among those who did not (20.2% vs 7.9%, P<.001).

Dr Lapostolle and colleagues point out that aspirin and clopidogrel . . . [Full Text of this Article]

Karen P. Alexander, MD
alexa019@mc.duke.edu

Eric D. Peterson, MD, MPH
Duke Clinical Research Institute
Duke University Medical Center
Durham, NC

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