Abstract
Background
The aim was to compare the peri-procedural biomarkers of coagulation and platelet activation in patients randomly allocated to intravenous enoxaparin or unfractionated heparin (UFH) in the ATOLL randomized trial (NCT00718471).
Methods and Results
A total of 129 patients (n = 58 enoxaparin and n = 71 UFH) admitted for ST-segment elevation myocardial infarction (STEMI) treated by percutaneous coronary intervention (PCI) were included in this substudy of the ATOLL trial. Activated partial thromboplastin time ratio, anti-Xa activity, von Willebrand factor antigen, prothrombin fragment 1 + 2 (F1 + 2), thrombin–antithrombin complex (TAT), tissue factor pathway inhibitor and soluble CD40 ligand were measured at sheath insertion (T1) and at the end of the PCI (T2) and correlated with 1-month clinical outcomes. Target anticoagulation levels at T2 were more readily achieved in patients receiving enoxaparin compared to those receiving UFH (80.3 vs 18.2%, p < 0.0001). Increased levels of F1 + 2 and TAT measured at T2 were associated with the incidence of the composite ischemic endpoint (p = 0.04 and p = 0.03) and all-cause mortality (p < 0.0001 and p = 0.002). Release of F1 + 2 between T1 and T2 also predicted the composite ischemic endpoint (312 ± 513 vs 37 ± 292, p = 0.04) and net clinical outcome (185 ± 405 vs 3.2 ± 278, p = 0.03).
Conclusions
During primary PCI, enoxaparin achieved therapeutic levels more frequently than UFH. Higher level of thrombin generation measured at the end of the PCI procedure was associated with more frequent ischemic events.
Similar content being viewed by others
References
Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the Management of Acute Myocardial Infarction in Patients Presenting with ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119–77.
Silvain J, Beygui F, Barthélémy O, Pollack C Jr, Cohen M, Zeymer U, et al. Efficacy and safety of enoxaparin versus unfractionated heparin during percutaneous coronary intervention: systematic review and meta-analysis. BMJ. 2012;3(344):e553.
Montalescot G, Zeymer U, Silvain J, Boulanger B, Cohen M, Goldstein P, et al. Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: the international randomised open-label ATOLL trial. Lancet. 2011;378(9792):693–703.
Collet JP, Huber K, Cohen M, Zeymer U, Goldstein P, Pollack C Jr, et al. A direct comparison of intravenous enoxaparin with unfractionated heparin in primary percutaneous coronary intervention (from the ATOLL trial). Am J Cardiol. 2013;112(9):1367–72.
Montalescot G, Bal-dit-Sollier C, Chibedi D, Collet JP, Soulat T, Dalby M, et al. Comparison of effects on markers of blood cell activation of enoxaparin, dalteparin, and unfractionated heparin in patients with unstable angina pectoris or non ST-segment elevation acute myocardial infarction (the ARMADA study). Am J Cardiol. 2003;91(8):925–30.
Montalescot G, Collet JP, Lison L, Choussat R, Ankri A, Vicaut E, et al. Effects of various anticoagulant treatments on von Willebrand factor release in unstable angina. J Am Coll Cardiol. 2000;36(1):110–4.
Becker RC, Mahaffey KW, Yang H, Marian AJ, Furman MI, Michael Lincoff A, et al. Heparin-associated anti-Xa activity and platelet-derived prothrombotic and proinflammatory biomarkers in moderate to high-risk patients with acute coronary syndrome. J Thromb Thrombolysis. 2011;31(2):146–53.
Montalescot G, White HD, Gallo R, Cohen M, Steg PG, Aylward PE, et al. Enoxaparin versus unfractionated heparin in elective percutaneous coronary intervention. N Engl J Med. 2006;355(10):1006–17.
Navarese EP, De Luca G, Castriota F, Kozinski M, Gurbel PA, Gibson CM, et al. Low-molecular-weight heparins vs. unfractionated heparin in the setting of percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis. J Thromb Haemost. 2011;9(10):1902–15.
Borentain M, Montalescot G, Bouzamondo A, Choussat R, Hulot JS, Lechat P. Low-molecular-weight heparin vs. unfractionated heparin in percutaneous coronary intervention: a combined analysis. Catheter Cardiovasc Interv. 2005;65(2):212–21.
Ferguson JJ, Califf RM, Antman EM, Cohen M, Grines CL, Goodman S, et al. Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial. JAMA. 2004;292(1):45–54.
Mehta SR, Yusuf S, Granger CB, Wallentin L, Peters RJ, Bassand JP, et al. Design and rationale of the MICHELANGELO Organization to Assess Strategies in Acute Ischemic Syndromes (OASIS)-5 trial program evaluating fondaparinux, a synthetic factor Xa inhibitor, in patients with non-ST-segment elevation acute coronary syndromes. Am Heart J. 2005;150(6):1107.
Hirsh J, Raschke R. Heparin and low-molecular-weight heparin: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 Suppl):188S–203S.
Silvain J, Beygui F, Ankri A, Bellemain-Appaix A, Pena A, Barthelemy O, et al. Enoxaparin anticoagulation monitoring in the catheterization laboratory using a new bedside test. J Am Coll Cardiol. 2004;55(7):617–25.
Montalescot G, Cohen M, Salette G, Desmet WJ, Macaya C, Aylward PE, et al. Impact of anticoagulation levels on outcomes in patients undergoing elective percutaneous coronary intervention: insights from the STEEPLE trial. Eur Heart J. 2008;29(4):462–71.
Li YH, Teng JK, Tsai WC, Tsai LM, Lin LJ, Guo HR, et al. Prognostic significance of elevated hemostatic markers in patients with acute myocardial infarction. J Am Coll Cardiol. 1999;33(6):1543–8.
Peternel P, Terbizan M, Tratar G, Bozic M, Horvat D, Salobir B, et al. Markers of hemostatic system activation during treatment of deep vein thrombosis with subcutaneous unfractionated or low-molecular weight heparin. Thromb Res. 2002;105(3):241–6.
Ardissino D, Merlini PA, Ka Bauer, Galvani M, Ottani F, Franchi F, et al. Coagulation activation and long-term outcome in acute coronary syndromes. Blood. 2003;102(8):2731–5.
Soncini M, Gasparini P, Lorena M, Motta A, Cimminiello C. Prognostic significance of markers of thrombin generation in the acute and chronic phases of non cardioembolic ischemic stroke. Miner Cardioangiol. 2000;48(11):349–56.
Biasucci LM, Liuzzo G, Caligiuri G, Quaranta G, Andreotti F, Sperti G, et al. Temporal relation between ischemic episodes and activation of the coagulation system in unstable angina. Circulation. 1996;93(12):2121–7.
Hoffmeister HM, Jur M, Wendel HP, Heller W, Seipel L. Alterations of coagulation and fibrinolytic and kallikrein-kinin systems in the acute and postacute phases in patients with unstable angina pectoris. Circulation. 1995;91(10):2520–7.
Pa Merlini, Ka Bauer, Oltrona L, Ardissino D, Cattaneo M, Belli C, et al. Persistent activation of coagulation mechanism in unstable angina and myocardial infarction. Circulation. 1994;90(1):61–8.
Granger CB, Becker R, Tracy RP, Califf RM, Topol EJ, Pieper KS, et al. Thrombin generation, inhibition and clinical outcomes in patients with acute myocardial infarction treated with thrombolytic therapy and heparin: results from the GUSTO-I Trial. J Am Coll Cardiol. 1998;31(3):497–505.
Elmas E, Kaelsch T, Wolpert C, Sueselbeck T, Bertsch T, Dempfle CE, et al. Assessment of markers of thrombin generation in patients with acute myocardial infarction complicated by ventricular fibrillation. Clin. Cardiol. 2006;29(4):165–9.
Petersen JL, Mahaffey KW, Hasselblad V, Antman EM, Cohen M, Goodman SG, et al. Efficacy and bleeding complications among patients randomized to enoxaparin or unfractionated heparin for antithrombin therapy in non-ST-Segment elevation acute coronary syndromes: a systematic overview. JAMA. 2004;292(1):89–96.
Stone GW, Witzenbichler B, Guagliumi G, for the HORIZONS-AMI Trial Investigators, et al. Bivalirudin during primary PCI in acute myocardial infarction. N Engl J Med. 2008;358(21):2218–30.
Steg PG, van’t Hof A, Hamm CW, for the EUROMAX Investigators, et al. Bivalirudin started during emergency transport for primary PCI. N Engl J Med. 2013;369(23):2207–17.
Acknowledgements
We would like to thank Nicolas Vignolles, Benjamin Bertin, Anzaha Ghalia, Karine Brochard, and Sissel Paulsrud for their technical assistance. Link to the webpage of the department http://pitiesalpetriere.aphp.fr/departement-de-cardiologie.
Author information
Authors and Affiliations
Consortia
Corresponding author
Ethics declarations
Funding
This study was supported by Sanofi-Aventis and ACTION Study Group, www.action-coeur.org.
Conflict of interest
J Silvain has received research grants, honorarium or travel support from Actelion, Amed, Amgen, Algorythm, Astra-Zeneca, Bayer, Daiichi-Sankyo, Eli Lilly, Fondation de France, Gilead Science, Iroko Cardio, Sanofi-Aventis and Saint-Jude Medical; M. Kerneis has received research grants from Sanofi, Fédération Française de Cardiologie, and Société Française de Cardiologie, and lectures and consulting fees from ESC, AstraZeneca, Daiichi-Sankyo, and Bayer; E. Vicaut has received research grants from Boehringer, Pfizer, Sanofi, LFB, Abbott, Fresenius, Medtronic, Hexacath, CERC, Novartis, and Elli Lilly; J.P. Collet has received research grants or honorarium from AstraZeneca, Bayer, Bristol-Myers Squibb, Daiichi-Sankyo, Eli-Lilly, Fédération Française de Cardiologie, Lead-Up, Medtronic, MSD, Sanofi-Aventis, and WebMD; G. Montalescot has received research grants or honorarium from ADIR, Amgen, AstraZeneca, Bayer, Berlin Chimie AG, Boehringer Ingelheim, Bristol-Myers Squibb, Beth Israel Deaconess Medical, Brigham Women’s Hospital, Cardiovascular Research Foundation, Celladon, CME Resources, Daiichi-Sankyo, Eli-Lilly, Europa, Elsevier, Fédération Française de Cardiologie, Fondazione Anna Maria Sechi per il Cuore, Gilead, ICAN, Janssen, Lead-Up, Menarini, Medtronic, MSD, Pfizer, Sanofi-Aventis, Servier, The Medicines Company, TIMI Study Group, and WebMD; S.A. O’Connor, Yan Yan, M. Hauguel-Moreau, M. Zeitouni, P. Overtchouk, A. Ankri, D. Brugier, P. Ecollan, and S. Gallier declare no potential conflicts of interest that might be relevant to this work.
Rights and permissions
About this article
Cite this article
Silvain, J., O’Connor, S.A., Yan, Y. et al. Biomarkers of Thrombosis in ST-Segment Elevation Myocardial Infarction: A Substudy of the ATOLL Trial Comparing Enoxaparin Versus Unfractionated Heparin. Am J Cardiovasc Drugs 18, 503–511 (2018). https://doi.org/10.1007/s40256-018-0294-z
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40256-018-0294-z