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October 15, 2019

Study Evaluates Preprocedural Anticoagulation for Patients With STEMI Undergoing Primary PCI

October 15, 2019—Online in Catheterization and Cardiovascular Interventions, Warren J. Cantor, MD, et al published findings from an evaluation of upstream anticoagulation for patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). The investigators sought to assess the relationship between preprocedural anticoagulation use and clinical and angiographic outcomes.

The study included patients enrolled in the TOTAL trial, which studied routine aspiration thrombectomy with PCI versus PCI alone in patients with STEMI undergoing primary PCI.

As summarized in Catheterization and Cardiovascular Interventions, patients enrolled in the TOTAL trial were stratified based on whether or not they had received any parenteral anticoagulant before randomization and PCI. The TOTAL trial enrolled 10,064 patients who underwent PCI. Preprocedural anticoagulation was used in 6,381 patients (63%). The most common anticoagulant was intravenous unfractionated heparin, used in 5,188 patients (81%).

The investigators compared baseline and procedural characteristics. For 1‐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. Patients who received preprocedural anticoagulation had higher rates of thrombolysis in myocardial infarction (TIMI) grade 2–3 flow or TIMI grade 3 flow and lower grades of thrombus before PCI.

The investigators found that 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 coronary artery bypass graft surgery and minor bleeding at 1 year, but there were no significant differences in death, stroke, recurrent MI, cardiogenic shock, or congestive heart failure.

The investigators in Catheterization and Cardiovascular Interventions concluded that preprocedural anticoagulation is associated with improved flow and reduced thrombus in the infarct-related artery before PCI and less bailout thrombectomy during PCI but with no difference in death, recurrent infarction, or heart failure at 1 year.

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