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

Montalescot, Gilles; Zeymer, Uwe; Silvain, Jean‐François; Boulanger, Bertrand; Cohen, Marc; Goldstein, Patrick; Ecollan, Patrick; Combes, X.; Huber, Kurt; Pollack, Charles V.; Bénezet, Jean-François; Stibbe, Olivier; Filippi, Emmanuelle; Teiger, Emmanuel; Cayla, Guillaume; Elhadad, Simon; Adnet, Frédéric; Chouihed, Tahar; Gallula, Sébastien; Greffet, Agnès; Aout, Mounir; Collet, Jean‐Philippe; Vicaut, Éric

doi:10.1016/s0140-6736(11)60876-3

Cited by 270 publications

(125 citation statements)

References 30 publications

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“…19 Montalscat et al, observed that enoxaparin has no difference in death rate and operation success rate in comparison to heparin. 20 In Stone et al, study, the reported rate of death for heparin group was 3.1% which was similar to our study, whereas in Bonello et al study the rate of death for heparin group was lower and reported about 1.1%. 17,18 Zijlstra et al, observed that heparin prescription group in comparison with no heparin prescription group had lower 30-day death rate (1.6% versus 3.4%).…”

Section: Vd 2--3 Vdsupporting

confidence: 89%

The effect of heparin prescription before primary PCI on long-term and short-term clinical and para clinical results and the mortality of patients with acute coronary syndrome

Zamani

Abdollahi

Mardi

2018

Int J Basic Clin Pharmacol

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INTRODUCTIONCoronary artery disease (CAD) is the main cause of death, morbidity and disability in the world and their prevalence is highly increasing in developing countries. In CAD patients, acute coronary syndrome (ACS) has the most importance because of the high possibility of unpleasant cardiovascular events during follow-up was more in these patients. In 2008, 7.3 million (12.8%) out of 57 million deaths was because of myocardial infraction. In the United States, almost 650 thousand patients get new acute myocardial infraction (AMI) per year. The rate of early death (30 days) with AMI is about 30% and more than half of these cases occur before reaching to the hospital. 1,2During the last two decades, the rate of the death of coronary disease is decreasing in developed countries, whereas it is increasing in developing countries which is mostly because of long lifetime, urbanization and lifestyle changes. In the United States, the adjusted rate of death based age due to coronary disease has been declined to two third in four last decades which is the reflection of better diagnosis and reduce risk factors and also improvement of faster ABSTRACT Background: Primary PCI (PPCI) is the main reperfusion treatment for STsegment elevation myocardial infarction (STEMI). Anticoagulation therapy should be administered in patients undergoing PCI in order to limit the ischemic complications. In this study, we evaluated the effect of bolus unfractionated heparin (UFH) before PPCI on clinical outcome of patients with STEMI. Methods: In this randomized clinical trial, 196 patients (72.4% male with mean age of 63.02±13.37 years) with STEMI undergoing PPCI were randomly assigned to receive bolus UFH 60-90 U/kg in emergency room (case group) or during PCI (control group). Clinical outcomes, 30 day mortality, hematoma, left ventricle function improvement during follow-up were compared between groups. Results: In both groups there was good flow in the involved coronary artery after PCI. Case group compared to control group had significantly more cases with improved LVEF (28.1% vs. 9.7%, p=0.005). Also, case group compared to control group had more hematoma (3.1% vs. 0%, p=0.24) and higher mortality rate (6% vs. 4.2%, p=0.56) which had no significant difference between groups. Conclusions: PPCI in patients with STEMI accompanies with acceptable coronary flow irrespective of receiving bolus heparin. Receiving bolus heparin in these patients may have improved left ventricle function by increasing the rate of reflow. However, using bolus heparin did not accompany with increased rate of bleeding and had no effect on 30 day mortality rate.

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Section: Vd 2--3 Vdsupporting

confidence: 89%

The effect of heparin prescription before primary PCI on long-term and short-term clinical and para clinical results and the mortality of patients with acute coronary syndrome

Zamani

Abdollahi

Mardi

2018

Int J Basic Clin Pharmacol

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“…UFH titrated to an appropriate activated clotting time is a familiar and well-tested strategy for anticoagulant therapy in the setting of PPCI [46,47] , compared to enoxaparin which has been studied less extensively in this setting. Moreover, the ATOLL trial comparing intravenous enoxaprin with UFH for PPCI failed to meet its primary composite endpoint (30-d death, complication of myocardial infarction, procedural failure and major bleeding) [48] . Thus, European guidelines recommend UFH in Class Ⅰ, level of evidence C, while enoxaparin has an indication of Class Ⅱb, level of evidence B [42] .…”

Section: Anticoagulantsmentioning

confidence: 99%

“…Thus, European guidelines recommend UFH in Class Ⅰ, level of evidence C, while enoxaparin has an indication of Class Ⅱb, level of evidence B [42] . However, European guidelines stated that enoxaparin should be preferred over UFH [42] , based on the considerable clinical experience with enoxaparin in other PCI settings [42] and on considerations derived from the ATOLL trial [48] . Particularly, although the primary endpoint was not reached, there were reductions in the composite main secondary endpoint of death, recurrent myocardial infarction or ACS or urgent revascularization, and in other secondary composite endpoints, such as death, or resuscitated cardiac arrest and death, or complication of myocardial infarction, and there was no indication of increased bleeding from use of enoxaparin over UFH [48] .…”

Section: Anticoagulantsmentioning

confidence: 99%

“…However, European guidelines stated that enoxaparin should be preferred over UFH [42] , based on the considerable clinical experience with enoxaparin in other PCI settings [42] and on considerations derived from the ATOLL trial [48] . Particularly, although the primary endpoint was not reached, there were reductions in the composite main secondary endpoint of death, recurrent myocardial infarction or ACS or urgent revascularization, and in other secondary composite endpoints, such as death, or resuscitated cardiac arrest and death, or complication of myocardial infarction, and there was no indication of increased bleeding from use of enoxaparin over UFH [48] . Moreover, a recent meta-analysis of 23 trials, including 30966 patients undergoing PCI (33.1% PPCI for STEMI, 28.2% rescue PCI, and 38.7% with non STelevation ACS or stable patients), showed that enoxaparin was associated with a significant relative and absolute risk reduction of mortality, along with a significant reduction of major bleeding, especially in patients treated with PPCI for STEMI [49] .…”

Section: Anticoagulantsmentioning

confidence: 99%

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Coronary thrombus in patients undergoing primary PCI for STEMI: Prognostic significance and management

Vecchio¹

2014

WJC

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Acute ST-elevation myocardial infarction (STEMI) usually results from coronary atherosclerotic plaque disruption with superimposed thrombus formation. Detection of coronary thrombi is a poor prognostic indicator, which is mostly proportional to their size and composition. Particularly, intracoronary thrombi impair both epicardial blood flow and myocardial perfusion, by occluding major coronary arteries and causing distal embolization, respectively. Thus, although primary percutaneous coronary intervention is the preferred treatement strategy in STEMI setting, the associated use of adjunctive antithrombotic drugs and/or percutaneous thrombectomy is crucial to optimize therapy of STEMI patients, by improving either angiographical and clinical outcomes. This review article will focus on the prognostic significance of intracoronary thrombi and on current antithrombotic pharmacological and interventional strategies used in the setting of STEMI to manage thrombotic lesions.© 2014 Baishideng Publishing Group Inc. All rights reserved. Key words: ST-elevation myocardial infarction; Intracoronary thrombosis; Primary percutaneous coronary intervention; Antithrombotic therapies; Coronary thrombectomyCore tip: Intracoronary thrombosis, is the basic pathophysiologic event in acute ST-elevation myocardial infarction (STEMI), and thrombi are very frequently detected in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). Thrombus burden and components are important determinants of prognosis in STEMI, being well-known risk factors for longterm adverse cardiovascular events, distal embolization and stent thrombosis. As a result, percutaneous management of lesions with a consistent thrombotic burden is still challenging in the setting of PPCI for STEMI. Therefore, several pharmacological and interventional strategies, such as thrombectomy have been developed in order to improve PPCI's safety and efficacy, by reducing thrombus burden.

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“…ций, при отсутствии увеличения частоты геморрагиче-ских осложнений по сравнению с группой НФГ [34]. Пер-вичное ЧКВ может быть выполнено после внутривен-ного введения болюса эноксапарина в дозе 0,5 мг/кг, при процедуре длительностью более 2 час необходи-мо введение дополнительного болюса 0,25 мг/кг.…”

Section: The Use Of Enoxaparin In Acs применение эноксапарина при оксunclassified

The Use of Enoxaparin in Acute Coronary Syndrome

Смирнова

Yаkushin

2016

Racionalʹnaâ farmakoterapiâ v kardiologii

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1 Областной клинический кардиологический диспансер. ул. Стройкова, 96, Рязань, 390026 Россия 2 Рязанский государственный медицинский университет им. академика И.П. Павлова ул. Высоковольтная, 9, Рязань, 390026 Россия В статье обсуждаются вопросы выбора антикоагулянтов при различных вариантах течения острого коронарного синдрома (ОКС). Согласно современным рекомендациям в качестве антикоагулянтов при ОКС применяются три группы препаратов: нефракционированный и низко-молекулярные гепарины (НФГ и НМГ), фондапаринукс и бивалирудин. НФГ на протяжении нескольких десятилетий был основным парен-теральным антикоагулянтом для терапии ОКС, в том числе при чрезкожных коронарных вмешательствах, однако целый ряд ограничений и побочных эффектов, свойственных этому препарату, способствовали появлению новых антикоагулянтов с меньшей молекулярной массой. Среди НМГ, обладающих более высокой биодоступностью и значительным удобством применения, только эноксапарин имеет достоверное клиническое преимущество перед НФГ по влиянию на прогноз больных с ОКС. При этом на протяжении всего периода ОКС, в том числе во время инвазивных процедур, смена препаратов гепарина крайне нежелательна, т.к. переход с эноксапарина на НФГ и наоборот не только уменьшает эффективность лечения, но и увеличивает риск развития кровотечений. Оптимальный профиль эффективность/безопасность при ОКС без подъема сегмента ST вне зависимости от выбранной тактики ведения имеет фондапаринукс, при невозможности его назначения аль-тернативой для проведения антикоагулянтной терапии являются эноксапарин или НФГ. Бивалирудин -оптимальная альтернатива НФГ в со-четании с блокаторами GP IIb/IIIa рецепторов тромбоцитов при инвазивной тактике лечения. У больных с нарушенной функцией почек при скорости клубочковой фильтрации (СКФ)<30 мл/мин/1,73м 2 дозу эноксапарина необходимо снизить до 1 мг/кг 1 раз в сут, при СКФ<15 мл/мин/1,73м 2 препарат противопоказан. Фондапаринукс по безопасности имеет преимущества перед эноксапарином у больных с хронической болезнью почек, однако при СКФ<20 мл/мин/1,73м 2 назначать препарат не рекомендуется, в данной ситуации следует отдать предпочте-ние НФГ в связи с легкостью мониторирования антикоагулянтной активности и возможностью быстрой нейтрализации его активности в слу-чае кровотечения.Ключевые слова: острый коронарный синдром, нефракционированный гепарин, эноксапарин, фондапаринукс, бивалирудин. The article discusses the choice of anticoagulant in different patterns of acute coronary syndrome (ACS). According to current recommendations three groups of agents are used as anticoagulants in ACS: unfractionated heparin (UFH) and low molecular weight heparin (LMWH), fondaparinux, and bivalirudin. UFH was the main parenteral anticoagulant therapy for ACS for several decades, including percutaneous coronary interventions, but a number of limitations and side effects of the drug contributed to the emergence of new anticoagulants with lower molecular weight. Among the LMWH, which have a higher bioavailability and significant convenience of administration, ...

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

Cited by 270 publications

References 30 publications

The effect of heparin prescription before primary PCI on long-term and short-term clinical and para clinical results and the mortality of patients with acute coronary syndrome

The effect of heparin prescription before primary PCI on long-term and short-term clinical and para clinical results and the mortality of patients with acute coronary syndrome

Coronary thrombus in patients undergoing primary PCI for STEMI: Prognostic significance and management

The Use of Enoxaparin in Acute Coronary Syndrome

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