Anticoagulation with otamixaban and ischemic events in non-ST-segment elevation acute coronary syndromes: the TAO randomized clinical trial.

Abstract

IMPORTANCE:

The optimal anticoagulant for patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) managed with an invasive strategy remains controversial.

OBJECTIVE:

To compare the clinical efficacy and safety of otamixaban, a novel intravenous direct factor Xa inhibitor, with that of unfractionated heparin plus downstream eptifibatide in patients with NSTE-ACS undergoing a planned early invasive strategy.

DESIGN, SETTING, AND PARTICIPANTS:

Randomized, double-blind, active-controlled superiority trial that enrolled 13,229 patients with NSTE-ACS and a planned early invasive strategy, at 568 active sites in 55 countries and conducted between April 2010 and February 2013. A planned interim analysis was conducted for otamixaban dose selection.

INTERVENTIONS:

Eligible participants were randomized to otamixaban (bolus and infusion, at 1 of 2 doses) or unfractionated heparin plus, at the time of percutaneous coronary intervention, eptifibatide. The otamixaban dose selected at interim analysis was an intravenous bolus of 0.080 mg/kg followed by an infusion of 0.140 mg/kg per hour.

MAIN OUTCOMES AND MEASURES:

The primary efficacy outcome was the composite of all-cause death or new myocardial infarction through day 7.

RESULTS:

Rates of the primary efficacy outcome were 5.5% (279 of 5105 patients) randomized to receive otamixaban and 5.7% (310 of 5466 patients) randomized to receive unfractionated heparin plus eptifibatide (adjusted relative risk, 0.99 [95% CI, 0.85-1.16]; P = .93). There were no differences for the secondary end points, including procedural thrombotic complications. The primary safety outcome of Thrombosis in Myocardial Infarction major or minor bleeding through day 7 was increased by otamixaban (3.1% vs 1.5%; relative risk, 2.13 [95% CI, 1.63-2.78]; P < .001). Results were consistent across prespecified subgroups.

CONCLUSIONS AND RELEVANCE:

Otamixaban did not reduce the rate of ischemic events relative to unfractionated heparin plus eptifibatide but did increase bleeding. These findings do not support the use of otamixaban for patients with NSTE-ACS undergoing planned early percutaneous coronary intervention.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT01076764.

• Authors: Philippe Gabriel Steg, Shamir R Mehta, Charles V Pollack Jr, Christoph Bode, Marc Cohen, William J French, James Hoekstra, Sunil V Rao, Witold Ruzyllo, Juan M Ruiz-Nodar, Manel Sabaté, Petr Widimsky, Robert Gabor Kiss, Jose Luis Navarro Estrada, Hanoch Hod, Prafulla Kerkar, Sema Guneri, Murat Sezer, Mikhail Ruda, José Carlos Nicolau, Claudio Cavallini, Iftikhar Ebrahim, Ivo Petrov, Jae-Hyung Kim, Myung-Ho Jeong, Gabriel Arturo Ramos Lopez, Peep Laanmets, Frantisek Kovar, Christophe Gaudin, Karen C Fanouillere, Pascal Minini, Elaine B Hoffman, Angele Moryusef, Stephen D Wiviott, Marc S Sabatine, TAO Investigators
• Journal: JAMA (JAMA) Vol. 310 Issue 11 Pg. 1145-55 (Sep 18 2013) ISSN: 1538-3598 [Electronic] United States
• PMID: 23995608 (Publication Type: Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)

Chemical References

• Anticoagulants
• Cyclic N-Oxides
• Factor Xa Inhibitors
• Peptides
• Platelet Glycoprotein GPIIb-IIIa Complex
• Pyridines
• Heparin
• Eptifibatide
• otamixaban

Topics

• Acute Coronary Syndrome (complications, drug therapy)
• Adult
• Aged
• Aged, 80 and over
• Anticoagulants (adverse effects, therapeutic use)
• Cause of Death
• Cyclic N-Oxides (adverse effects, therapeutic use)
• Double-Blind Method
• Eptifibatide
• Factor Xa Inhibitors
• Female
• Hemorrhage (chemically induced)
• Heparin (therapeutic use)
• Humans
• Infusions, Intravenous
• Injections, Intravenous
• Male
• Middle Aged
• Myocardial Infarction (etiology, prevention & control)
• Peptides (therapeutic use)
• Percutaneous Coronary Intervention
• Platelet Glycoprotein GPIIb-IIIa Complex (antagonists & inhibitors)
• Pyridines (adverse effects, therapeutic use)
• Risk
• Survival Analysis
• Treatment Outcome