Aspirin Plus Coumarin Versus Aspirin Alone in the Prevention of Reocclusion After Fibrinolysis for Acute Myocardial Infarction

Abstract

Background-Despite the use of aspirin, reocclusion of the infarct-related artery occurs in Ϸ30% of patients within the first year after successful fibrinolysis, with impaired clinical outcome. This study sought to assess the impact of a prolonged anticoagulation regimen as adjunctive to aspirin in the prevention of reocclusion and recurrent ischemic events after fibrinolysis for ST-elevation myocardial infarction. Methods and Results-At coronary angiography Ͻ48 hours after fibrinolytic therapy, 308 patients receiving aspirin and intravenous heparin had a patent infarct-related artery (Thrombolysis In Myocardial Infarction [TIMI] grade 3 flow). They were randomly assigned to standard heparinization and continuation of aspirin alone or to a 3-month combination of aspirin with moderate-intensity coumarin, including continued heparinization until a target international normalized ratio (INR) of 2.0 to 3.0. Angiographic and clinical follow-up were assessed at 3 months. Median INR was 2.6 (25 to 75th percentiles 2.1 to 3.1). Reocclusion (ՅTIMI grade 2 flow) was observed in 15% of patients receiving aspirin and coumarin compared with 28% in those receiving aspirin alone (relative risk [RR], 0.55; 95% CI 0.33 to 0.90; PϽ0.02). TIMI grade 0 to 1 flow rates were 9% and 20%, respectively (RR, 0.46; 95% CI, 0.24 to 0.89; PϽ0.02). Survival rates free from reinfarction and revascularization were 86% and 66%, respectively (PϽ0.01). Bleeding (TIMI major and minor) was infrequent: 5% versus 3% (PϭNS). Conclusions-As adjunctive to aspirin, a 3-month-regimen of moderate-intensity coumarin, including heparinization until the target INR is reached, markedly reduces reocclusion and recurrent events after successful fibrinolysis. This conceptual study provides a mechanistic rationale to further investigate the role of prolonged anticoagulation after fibrinolytic therapy. (Circulation. 2002;106:659-665.)

Amount of ST wave resolution in patients with and without spontaneous coronary reperfusion in the infarct -related artery after primary PCI: an observational study

“…There was not a single reinfarction episode during an observation period of 6579 patient hours. This is in contrast with the 10-20% reocclusion of the IRA observed in patients with STEMI, post-thrombolysis (15).…”

Anticoagulation Therapy in Atrial Fibrillation in Combination With Acute Myocardial Infarction Influences Long-Term Outcome

“…[21][22][23] Moderate-to highintensity OAC (international normalized ratio Ͼ2.0) plus ASA, however, resulted in fewer reocclusions after successful lysis than ASA alone. 24 This combination therapy was also found to reduce the composite of death, reinfarction, and stroke in 2 recent postinfarction studies (Antithrombotics in the Secondary Prevention of Events in Coronary Thrombosis-2 [ASPECT-2, nϭ993] and the Warfarin, Aspirin Reinfarction Study-2 [WARIS-2, nϭ3640]), 9,10 although it was associated with a doubling in the low rate of nonfatal bleeding complications. This caused the European Task Force on the Management of Acute ST-Elevation Myocardial Infarction 15 to state that currently, no recommendations can be made for the combined routine use of OACs and aspirin after AMI, whereas the American counterpart to this task force has an intermediate recommendation for combination therapy.…”

The Cardiovascular Disease Continuum Validated: Clinical Evidence of Improved Patient Outcomes

“…The addition of low-intensity anticoagulation therapy (warfarin, median international normalized ratio 1.8 IU) to aspirin does not provide any clinical advantage over aspirin monotherapy. 88 However, moderate-to high-intensity anticoagulant treatment (median international normalized ratio Ͼ2.0 IU) as an adjunct to aspirin has demonstrated a positive effect on reocclusion rates 89 and risk of recurrent cardiovascular events or death. 90 The efficacy and safety of the combination of aspirin plus clopidogrel in patients with STEMI was investigated in the Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis in Myocardial Infarction 28 (CLARITY-TIMI 28) trial, 91 in which patients received clopidogrel or placebo in addition to aspirin and a fibrinolytic agent.…”