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Watanabe H, Natsuaki M, Morimoto T, Yamamoto K, Obayashi Y, Nishikawa R, Hamatani Y, Ando K, Domei T, Suwa S, Ogita M, Isawa T, Takenaka H, Yamamoto T, Ishikawa T, Hisauchi I, Wakabayashi K, Onishi Y, Hibi K, Kawai K, Yoshida R, Suzuki H, Nakazawa G, Kusuyama T, Morishima I, Ono K, Kimura T. Post-procedural Anticoagulation With Unfractionated Heparin in Acute Coronary Syndrome: Insight from the STOPDAPT-3 Trial. Am J Cardiol 2024; 226:83-96. [PMID: 38972535 DOI: 10.1016/j.amjcard.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 06/19/2024] [Accepted: 07/02/2024] [Indexed: 07/09/2024]
Abstract
The current guidelines for acute coronary syndrome (ACS) discourage the use of anticoagulation after percutaneous coronary intervention (PCI) without specific indications, although the recommendation is not well supported by evidence. In this post hoc analysis of the ShorT and OPtimal Duration of Dual AntiPlatelet Therapy-3 (STOPDAPT-3) trial, 30-day outcomes were compared between the 2 groups with and without post-PCI heparin administration among patients with ACS who did not receive mechanical support devices. The co-primary end points were the bleeding end point, defined as the Bleeding Academic Research Consortium type 3 or 5 bleeding, and the cardiovascular end point, defined as a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischemic stroke. Among 4,088 patients with ACS, 2,339 patients (57.2%) received post-PCI heparin. The proportion of patients receiving post-PCI heparin was higher among those with ST-elevation myocardial infarction compared with others (72.3% and 38.8%, p <0.001), and among patients with intraprocedural adverse angiographic findings compared with those without (67.6% and 47.5%, p <0.001). Post-PCI heparin compared with no post-PCI heparin was associated with a significantly increased risk of the bleeding end point (4.75% and 2.52%, adjusted hazard ratio 1.69, 95% confidence interval 1.15 to 2.46, p = 0.007) and a numerically increased risk of the cardiovascular end point (3.16% and 1.72%, adjusted hazard ratio 1.56, 95% confidence interval 0.98 to 2.46, p = 0.06). Higher hourly dose or total doses of heparin were also associated with higher incidence of both bleeding and cardiovascular events within 30 days. In conclusion, post-PCI anticoagulation with unfractionated heparin was frequently implemented in patients with ACS. Post-PCI heparin use was associated with harm in terms of increased bleeding without the benefit of reducing cardiovascular events. Trial identifier: STOPDAPT-3 ClinicalTrials.gov number, NCT04609111.
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Affiliation(s)
| | | | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan
| | - Ko Yamamoto
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Yuki Obayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Takenori Domei
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Manabu Ogita
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Tsuyoshi Isawa
- Department of Cardiology, Sendai Kousei Hospital, Sendai, Japan
| | | | - Takashi Yamamoto
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan
| | - Tetsuya Ishikawa
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Itaru Hisauchi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Kohei Wakabayashi
- Department of Cardiology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuko Onishi
- Department of Cardiology, Hiratsuka Kyosai Hospital, Hiratsuka, Japan
| | - Kiyoshi Hibi
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Kazuya Kawai
- Division of Cardiology, Chikamori Hospital, Kochi, Japan
| | - Ruka Yoshida
- Division of Cardiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Hiroshi Suzuki
- Division of Cardiology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Gaku Nakazawa
- Department of Cardiology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | | | - Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Kimura
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan.
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Yan Y, Guo J, Wang X, Wang G, Fan Z, Yin D, Wang Z, Zhang F, Tian C, Gong W, Liu J, Lu J, Li Y, Ma C, Vicaut E, Montalescot G, Nie S. Postprocedural Anticoagulation After Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction: A Multicenter, Randomized, Double-Blind Trial. Circulation 2024; 149:1258-1267. [PMID: 38406848 DOI: 10.1161/circulationaha.123.067079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 02/01/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Postprocedural anticoagulation (PPA) is frequently administered after primary percutaneous coronary intervention in ST-segment-elevation myocardial infarction, although no conclusive data support this practice. METHODS The RIGHT trial (Comparison of Anticoagulation Prolongation vs no Anticoagulation in STEMI Patients After Primary PCI) was an investigator-initiated, multicenter, randomized, double-blind, placebo-controlled, superiority trial conducted at 53 centers in China. Patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention were randomly assigned by center to receive low-dose PPA or matching placebo for at least 48 hours. Before trial initiation, each center selected 1 of 3 PPA regimens (40 mg of enoxaparin once daily subcutaneously; 10 U·kg·h of unfractionated heparin intravenously, adjusted to maintain activated clotting time between 150 and 220 seconds; or 0.2 mg·kg·h of bivalirudin intravenously). The primary efficacy objective was to demonstrate superiority of PPA to reduce the primary efficacy end point of all-cause death, nonfatal myocardial infarction, nonfatal stroke, stent thrombosis (definite), or urgent revascularization (any vessel) within 30 days. The key secondary objective was to evaluate the effect of each specific anticoagulation regimen (enoxaparin, unfractionated heparin, or bivalirudin) on the primary efficacy end point. The primary safety end point was Bleeding Academic Research Consortium 3 to 5 bleeding at 30 days. RESULTS Between January 10, 2019, and September 18, 2021, a total of 2989 patients were randomized. The primary efficacy end point occurred in 37 patients (2.5%) in both the PPA and placebo groups (hazard ratio, 1.00 [95% CI, 0.63 to 1.57]). The incidence of Bleeding Academic Research Consortium 3 to 5 bleeding did not differ between the PPA and placebo groups (8 [0.5%] vs 11 [0.7%] patients; hazard ratio, 0.74 [95% CI, 0.30 to 1.83]). CONCLUSIONS Routine PPA after primary percutaneous coronary intervention was safe but did not reduce 30-day ischemic events. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03664180.
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Affiliation(s)
- Yan Yan
- Center for Coronary Artery Disease (Y.Y., X.W., W.G., S.N.), Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center of Cardiovascular Diseases, Beijing, China (Y.Y., X.W., W.G., C.M., S.N.)
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China (Y.Y., X.W., W.G., C.M., S.N.)
| | - Jincheng Guo
- Beijing Luhe Hospital, Capital Medical University, Beijing, China (J.G., G.W.)
| | - Xiao Wang
- Center for Coronary Artery Disease (Y.Y., X.W., W.G., S.N.), Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center of Cardiovascular Diseases, Beijing, China (Y.Y., X.W., W.G., C.M., S.N.)
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China (Y.Y., X.W., W.G., C.M., S.N.)
| | - Guozhong Wang
- Beijing Luhe Hospital, Capital Medical University, Beijing, China (J.G., G.W.)
| | - Zeyuan Fan
- Civil Aviation General Hospital, Beijing, China (Z.F.)
| | - Delu Yin
- The First People's Hospital of Lianyungang, Jiangsu, China (D.Y.)
| | | | | | | | - Wei Gong
- Center for Coronary Artery Disease (Y.Y., X.W., W.G., S.N.), Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center of Cardiovascular Diseases, Beijing, China (Y.Y., X.W., W.G., C.M., S.N.)
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China (Y.Y., X.W., W.G., C.M., S.N.)
| | - Jiamin Liu
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications (J. Liu)
| | - Jiapeng Lu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China (J. Lu)
| | - Yongjun Li
- The Second Hospital of Hebei Medical University, Shijiazhuang, China (Y.L.)
| | - Changsheng Ma
- Arrhythmia Center (C.M.), Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center of Cardiovascular Diseases, Beijing, China (Y.Y., X.W., W.G., C.M., S.N.)
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China (Y.Y., X.W., W.G., C.M., S.N.)
| | - Eric Vicaut
- ACTION Study Group, Epidemiology and Clinic Research Unit, Lariboisière University Hospital, Paris, France (E.V.)
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France (G.M.)
| | - Shaoping Nie
- Center for Coronary Artery Disease (Y.Y., X.W., W.G., S.N.), Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center of Cardiovascular Diseases, Beijing, China (Y.Y., X.W., W.G., C.M., S.N.)
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, China (Y.Y., X.W., W.G., C.M., S.N.)
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Yan Y, Wang X, Guo J, Li Y, Ai H, Gong W, Que B, Zhen L, Lu J, Ma C, Montalescot G, Nie S. Rationale and design of the RIGHT trial: A multicenter, randomized, double-blind, placebo-controlled trial of anticoagulation prolongation versus no anticoagulation after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Am Heart J 2020; 227:19-30. [PMID: 32663660 DOI: 10.1016/j.ahj.2020.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 06/07/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Current guidelines recommend anticoagulation therapy during primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI). However, whether anticoagulation should be continued after pPCI has not been well investigated. METHODS/DESIGN The RIGHT trial is a prospective, multicenter, randomized, double-blind, placebo-controlled trial in STEMI patients treated with pPCI evaluating the prolongation of anticoagulation after the procedure. Patients are randomized in a 1:1 fashion to receive either prolonged anticoagulant or matching placebo (no anticoagulation) for at least 48 hours after the procedure. When randomized to anticoagulation prolongation, the patient is assigned to intravenous unfractionated heparin (UFH) or subcutaneous enoxaparin or intravenous bivalirudin (same drug and same regimen at each center). The primary efficacy endpoint is the composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, stent thrombosis (definite) or urgent revascularization (any vessel) at 30 days. The primary safety endpoint is major bleeding (BARC 3-5) at 30 days. Based on a superiority design and assuming a 35% relative risk reduction (from 7% to 4.5%), 2856 patients will be enrolled, accounting for a 5% drop-out rate (α = 0.05 and power = 80%). CONCLUSION The RIGHT trial tests the hypothesis that post-procedural anticoagulation is superior to no anticoagulation in reducing ischemic events in STEMI patients undergoing pPCI.
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Madhavan MV, Généreux P, Kirtane AJ, Xu K, Witzenbichler B, Mehran R, Stone GW. Is routine post-procedural anticoagulation warranted after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction? Insights from the HORIZONS-AMI trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 6:650-658. [DOI: 10.1177/2048872615592246] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Mahesh V Madhavan
- Columbia University Medical Center, New York-Presbyterian Hospital, USA
| | - Philippe Généreux
- Columbia University Medical Center, New York-Presbyterian Hospital, USA
- Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Canada
| | - Ajay J Kirtane
- Columbia University Medical Center, New York-Presbyterian Hospital, USA
- Cardiovascular Research Foundation, USA
| | - Ke Xu
- Cardiovascular Research Foundation, USA
| | | | - Roxana Mehran
- Cardiovascular Research Foundation, USA
- Icahn School of Medicine at Mount Sinai, USA
| | - Gregg W Stone
- Columbia University Medical Center, New York-Presbyterian Hospital, USA
- Cardiovascular Research Foundation, USA
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