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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, Gong W, Ma C, Wang X, Smith SC, Fonarow GC, Morgan L, Liu J, Vicaut E, Zhao D, Montalescot G, Nie S. Postprocedure Anticoagulation in Patients With Acute ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2022; 15:251-263. [PMID: 35144781 DOI: 10.1016/j.jcin.2021.11.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 11/19/2021] [Accepted: 11/30/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES This study sought to assess the association between postprocedural anticoagulation (PPAC) use and several clinical outcomes. BACKGROUND PPAC after primary percutaneous coronary intervention (pPCI) in patients with ST-segment elevation myocardial infarction (STEMI) may prevent recurrent ischemic events but may increase the risk of bleeding. No consensus has been reached on PPAC use. METHODS Using data from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome registry, conducted between 2014 and 2019, we stratified all STEMI patients who underwent pPCI according to the use of PPAC or not. Inverse probability of treatment weighting and a Cox proportional hazards model with hospital as random effect were used to analyze differences in in-hospital clinical outcomes: the primary efficacy endpoint was mortality and the primary safety endpoint was major bleeding. RESULTS Of 34,826 evaluable patients, 26,272 (75.4%) were treated with PPAC and were on average younger, more stable at admission with lower bleeding risk score, more likely to have comorbidities and multivessel disease, and more often treated within 12 hours of symptom onset than those without PPAC. After inverse probability of treatment weighting adjustment for baseline differences, PPAC was associated with significantly reduced risk of in-hospital mortality (0.9% vs 1.8%; HR: 0.62; 95% CI: 0.43-0.89; P < 0.001) and a nonsignificant difference in risk of in-hospital major bleeding (2.5% vs 2.2%; HR: 1.05; 95% CI: 0.83-1.32; P = 0.14). CONCLUSIONS PPAC in STEMI patients after pPCI was associated with reduced mortality without increasing major bleeding complications. Dedicated randomized trials with contemporary STEMI management are needed to confirm these findings.
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Affiliation(s)
- Yan Yan
- Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China; Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wei Gong
- Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China; Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiao Wang
- Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China; Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Sidney C Smith
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Gregg C Fonarow
- Division of Cardiology, Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California, USA
| | - Louise Morgan
- International Quality Improvement Department, American Heart Association, Dallas, Texas, USA
| | - Jing Liu
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Eric Vicaut
- ACTION Study Group, Epidemiology and Clinic Research Unit, Lariboisière University Hospital, Paris, France
| | - Dong Zhao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Gilles Montalescot
- Sorbonne University, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Shaoping Nie
- Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China; Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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