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Acute stent thrombosis after primary percutaneous coronary intervention: insights from the EUROMAX trial (European Ambulance Acute Coronary Syndrome Angiography)

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  • Peter Clemmensen
  • Sebastian Wiberg
  • Arnoud Van't Hof
  • Efthymios N Deliargyris
  • Pierre Coste
  • Jurrien Ten Berg
  • Claudio Cavallini
  • Martial Hamon
  • Dariusz Dudek
  • Uwe Zeymer
  • Xavier Tabone
  • Steen D Kristensen
  • Debra Bernstein
  • Prodromos Anthopoulos
  • Jayne Prats
  • Philippe Gabriel Steg
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OBJECTIVES: This study sought to determine clinical, procedural, and treatment factors associated with acute stent thrombosis (AST) in the EUROMAX (European Ambulance Acute Coronary Syndrome Angiography) trial.

BACKGROUND: Bivalirudin started during transport for primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction significantly reduced major bleeding compared with heparin with or without glycoprotein IIb/IIIa inhibitors (GPI), but it was associated with an increase in AST.

METHODS: We compared patients with (n = 12) or without AST (n = 2,184) regarding baseline, clinical, and procedural characteristics and antithrombotic treatment strategies (choice of P2Y12 inhibitor, post-primary PCI bivalirudin infusion dose [0.25 mg/kg/h, or BIV-LOW] vs. [1.75 mg/kg/h, or BIV-PCI] vs. heparin ± GPI). Logistic regression was performed to identify independent correlates of AST.

RESULTS: The overall AST rate was 0.6% and was higher with bivalirudin than with heparin ± GPI (1.1% vs. 0.2%; p = 0.007). Median time to AST was 2.3 h (interquartile range: 1.9 to 2.8 h). Patients with AST had less hypertension (2 of 14 [14.0%] vs. 961 of 2,182 [44.0%]; p = 0.03), and more frequently received GPI (11 of 14 [78.6%] vs. 880 of 2,183 [40.3%]; p = 0.004). Multivariate analysis using Firth penalized maximum likelihood estimation found hypertension (odds ratio [OR]: 0.24, 95% confidence interval [CI]: 0.07 to 0.92; p = 0.037) and BIV-LOW (OR: 5.8, 95% CI: 1.5 to 22.2; p = 0.010) predictive of AST. Choice of P2Y12 inhibitor had no impact on AST. Compared with heparin ± GPI, AST rates were higher for BIV-LOW (11 of 670 [1.6%] vs. 2 of 947 [0.2%]; p = 0.008), but not different for BIV-PCI (1 of 244 [0.4%]; p = 0.588).

CONCLUSIONS: In this post-hoc analysis from EUROMAX, AST occurred very early and was not mitigated by the novel P2Y12 inhibitors. Prolonging the bivalirudin infusion at the PCI dose (but not at a lower dose) appeared to mitigate the risk of AST.

Original languageEnglish
JournalJACC. Cardiovascular interventions
Issue number1 Pt B
Pages (from-to)214-20
Number of pages7
Publication statusPublished - Jan 2015

    Research areas

  • Aged, Ambulances, Anticoagulants, Chi-Square Distribution, Coronary Angiography, Coronary Thrombosis, Drug Administration Schedule, Europe, Female, Heparin, Hirudins, Humans, Logistic Models, Male, Middle Aged, Multivariate Analysis, Myocardial Infarction, Odds Ratio, Peptide Fragments, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Predictive Value of Tests, Recombinant Proteins, Risk Factors, Stents, Time Factors, Treatment Outcome

ID: 46244173