Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: the international randomised open-label ATOLL trial

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• 作者：Prof Gilles Montalescot MD^a ; ^{gilles.montalescot@psl.aphp.fr"" rel=""nofollow} ; Uwe Zeymer MD^c ; Johanne Silvain MD^a ; Bertrand Boulanger MD^d ; Marc Cohen MD^f ; Patrick Goldstein MD^g ; Patrick Ecollan MD^b ; Xavier Combes MD^h ; Kurt Huber MD^j ; Charles Pollack Jr MD^k ; Jean-Franç ; ois Bé ; nezet MD^l ; Olivier Stibbe MDⁿ ; Emmanuelle Filippi MD^e ; Emmanuel Teiger MDⁱ ; Guillaume Cayla MD^m ; Simon Elhadad MD^o ; Fré ; dé ; ric Adnet MD^p ; Tahar Chouihed MD^q ; Sé ; bastien Gallula MD^r ; Agnè ; s Greffet MD^s ; Mounir Aout PhD^t ; Jean-Philippe Collet MD^a ; Eric Vicaut MD^t ; for the ATOLL Investigators
• 刊名：The Lancet
• 出版年：2011
• 出版时间：20 August 2011-26 August 2011
• 年：2011
• 卷：378
• 期：9792
• 页码：693-703
• 全文大小：340 K

文摘

Summary

Background

Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction has traditionally been supported by unfractionated heparin, which has never been directly compared with a new anticoagulant using consistent anticoagulation and similar antiplatelet strategies in both groups. We compared traditional heparin treatment with intravenous enoxaparin in primary PCI.

Methods

In a randomised open-label trial, patients presenting with ST-elevation myocardial infarction were randomly assigned (1:1) to receive an intravenous bolus of 0·5 mg/kg of enoxaparin or unfractionated heparin before primary PCI. Wherever possible, medical teams travelling in mobile intensive care units (ambulances) selected, randomly assigned (using an interactive voice response system at the central randomisation centre), and treated patients. Patients who had received any anticoagulant before randomisation were excluded. Patients and caregivers were not masked to treatment allocation. The primary endpoint was 30-day incidence of death, complication of myocardial infarction, procedure failure, or major bleeding. The main secondary endpoint was the composite of death, recurrent acute coronary syndrome, or urgent revascularisation. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCT00718471.

Findings

910 patients were assigned to treatment with enoxaparin (n=450) or unfractionated heparin (n=460). The primary endpoint occurred in 126 (28 % ) patients after anticoagulation with enoxaparin versus 155 (34 % ) patients on unfractionated heparin (relative risk [RR] 0·83, 95 % CI 0·68–1·01, p=0·06). The incidence of death (enoxaparin, 17 [4 % ] vs heparin, 29 [6 % ] patients; p=0·08), complication of myocardial infarction (20 [4 % ] vs 29 [6 % ]; p=0·21), procedure failure (100 [26 % ] vs 109 [28 % ]; p=0·61), and major bleeding (20 [5 % ] vs 22 [5 % ]; p=0·79) did not differ between groups. Enoxaparin resulted in a significantly reduced rate of the main secondary endpoint (30 [7 % ] vs 52 [11 % ] patients; RR 0·59, 95 % CI 0·38–0·91, p=0·015). Death, complication of myocardial infarction, or major bleeding (46 [10 % ] vs 69 [15 % ] patients; p=0·03), death or complication of myocardial infarction (35 [8 % ] vs 57 [12 % ]; p=0·02), and death, recurrent myocardial infarction, or urgent revascularisation (23 [5 % ] vs 39 [8 % ]; p=0·04) were all reduced with enoxaparin.

Interpretation

Intravenous enoxaparin compared with unfractionated heparin significantly reduced clinical ischaemic outcomes without differences in bleeding and procedural success. Therefore, enoxaparin provided an improvement in net clinical benefit in patients undergoing primary PCI.

Funding

Direction de la Recherche Clinique, Assistance Publique-Hôpitaux de Paris; Sanofi-Aventis.