Upstream anticoagulation for patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: Insights from the TOTAL trial.

Abstract

OBJECTIVES:

To assess the relationship between preprocedural anticoagulation use and clinical and angiographic outcomes.

BACKGROUND:

For patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), the optimal timing of anticoagulant administration remains uncertain.

METHODS:

Patients enrolled in the TOTAL trial were stratified based on whether or not they had received any parenteral anticoagulant prior to randomization and PCI. Baseline and procedural characteristics were compared. For one-year clinical outcomes, Cox proportional modeling adjusted on a propensity score was used to analyze differences between groups. Angiographic endpoints were analyzed by logistic regression models adjusted for propensity scores.

RESULTS:

In the trial, 10,064 patients were enrolled and underwent PCI. Preprocedural anticoagulation was used in 6,381 patients (63%).The most common anticoagulant was intravenous unfractionated heparin (5,188, 81%). Patients who received preprocedural anticoagulation had higher rates of TIMI-2-3 or TIMI-3 flow and lower grades of thrombus prior to PCI. Pretreatment with anticoagulation was associated with lower use of bailout thrombectomy, GP IIb/IIIa inhibitors, and intra-aortic balloon pump. After adjustment, preprocedural anticoagulation was associated with lower rates of CABG and minor bleeding at 1 year but there were no significant differences in death, stroke, recurrent MI, cardiogenic shock, or congestive heart failure.

CONCLUSIONS:

Preprocedural anticoagulation is associated with improved flow and reduced thrombus in the IRA prior to PCI, less bailout thrombectomy during PCI but no difference in death, recurrent infarction, or heart failure at 1 year.

• Authors: Warren J Cantor, Shahar Lavi, Vladimír Džavík, John Cairns, Asim N Cheema, Anthony Della Siega, Raul Moreno, Goran Stankovic, Sasko Kedev, Madhu K Natarajan, Yaniv Levi, Fei Yuan, Sanjit S Jolly
• Journal: Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions (Catheter Cardiovasc Interv) Vol. 96 Issue 3 Pg. 519-525 (09 01 2020) ISSN: 1522-726X [Electronic] United States
• PMID: 31613046 (Publication Type: Comparative Study, Journal Article, Multicenter Study, Research Support, Non-U.S. Gov't)
• Copyright: © 2019 Wiley Periodicals, Inc.

Chemical References

• Anticoagulants

Topics

• Administration, Intravenous
• Aged
• Anticoagulants (administration & dosage, adverse effects)
• Coronary Angiography
• Databases, Factual
• Drug Administration Schedule
• Female
• Heart Failure (mortality)
• Humans
• Male
• Middle Aged
• Percutaneous Coronary Intervention (adverse effects, mortality)
• Randomized Controlled Trials as Topic
• Recurrence
• Risk Assessment
• Risk Factors
• ST Elevation Myocardial Infarction (diagnosis, mortality, therapy)
• Shock, Cardiogenic (mortality)
• Stroke (mortality, prevention & control)
• Time Factors
• Treatment Outcome