title: Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: the international randomised open-label ATOLL trial.
abstract: BACKGROUND
  Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction has traditionally been supported by unfractionated heparin, which has never been directly compared with a new anticoagulant using consistent anticoagulation and similar antiplatelet strategies in both groups. We compared traditional heparin treatment with intravenous enoxaparin in primary PCI.
  
  
  METHODS
  In a randomised open-label trial, patients presenting with ST-elevation myocardial infarction were randomly assigned (1:1) to receive an intravenous bolus of 0·5 mg/kg of enoxaparin or unfractionated heparin before primary PCI. Wherever possible, medical teams travelling in mobile intensive care units (ambulances) selected, randomly assigned (using an interactive voice response system at the central randomisation centre), and treated patients. Patients who had received any anticoagulant before randomisation were excluded. Patients and caregivers were not masked to treatment allocation. The primary endpoint was 30-day incidence of death, complication of myocardial infarction, procedure failure, or major bleeding. The main secondary endpoint was the composite of death, recurrent acute coronary syndrome, or urgent revascularisation. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCT00718471.
  
  
  RESULTS
  910 patients were assigned to treatment with enoxaparin (n=450) or unfractionated heparin (n=460). The primary endpoint occurred in 126 (28%) patients after anticoagulation with enoxaparin versus 155 (34%) patients on unfractionated heparin (relative risk [RR] 0·83, 95% CI 0·68-1·01, p=0·06). The incidence of death (enoxaparin, 17 [4%] vs heparin, 29 [6%] patients; p=0·08), complication of myocardial infarction (20 [4%] vs 29 [6%]; p=0·21), procedure failure (100 [26%] vs 109 [28%]; p=0·61), and major bleeding (20 [5%] vs 22 [5%]; p=0·79) did not differ between groups. Enoxaparin resulted in a significantly reduced rate of the main secondary endpoint (30 [7%] vs 52 [11%] patients; RR 0·59, 95% CI 0·38-0·91, p=0·015). Death, complication of myocardial infarction, or major bleeding (46 [10%] vs 69 [15%] patients; p=0·03), death or complication of myocardial infarction (35 [8%] vs 57 [12%]; p=0·02), and death, recurrent myocardial infarction, or urgent revascularisation (23 [5%] vs 39 [8%]; p=0·04) were all reduced with enoxaparin.
  
  
  CONCLUSIONS
  Intravenous enoxaparin compared with unfractionated heparin significantly reduced clinical ischaemic outcomes without differences in bleeding and procedural success. Therefore, enoxaparin provided an improvement in net clinical benefit in patients undergoing primary PCI.
  
  
  BACKGROUND
  Direction de la Recherche Clinique, Assistance Publique-Hôpitaux de Paris; Sanofi-Aventis.
authors.affiliation: Institut de Cardiologie, CHU Pitié-Salpêtrière (AP-HP), Université Paris 6, Paris, France. gilles.montalescot@psl.aphp.fr
authors.forename: Gilles
authors.initials: G
authors.lastname: Montalescot
authors.forename: Uwe
authors.initials: U
authors.lastname: Zeymer
authors.forename: Johanne
authors.initials: J
authors.lastname: Silvain
authors.forename: Bertrand
authors.initials: B
authors.lastname: Boulanger
authors.forename: Marc
authors.initials: M
authors.lastname: Cohen
authors.forename: Patrick
authors.initials: P
authors.lastname: Goldstein
authors.forename: Patrick
authors.initials: P
authors.lastname: Ecollan
authors.forename: Xavier
authors.initials: X
authors.lastname: Combes
authors.forename: Kurt
authors.initials: K
authors.lastname: Huber
authors.forename: Charles
authors.initials: C
authors.lastname: Pollack
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Bénezet
authors.forename: Olivier
authors.initials: O
authors.lastname: Stibbe
authors.forename: Emmanuelle
authors.initials: E
authors.lastname: Filippi
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Teiger
authors.forename: Guillaume
authors.initials: G
authors.lastname: Cayla
authors.forename: Simon
authors.initials: S
authors.lastname: Elhadad
authors.forename: Frédéric
authors.initials: F
authors.lastname: Adnet
authors.forename: Tahar
authors.initials: T
authors.lastname: Chouihed
authors.forename: Sébastien
authors.initials: S
authors.lastname: Gallula
authors.forename: Agnès
authors.initials: A
authors.lastname: Greffet
authors.forename: Mounir
authors.initials: M
authors.lastname: Aout
authors.forename: Jean-Philippe
authors.initials: JP
authors.lastname: Collet
authors.forename: Eric
authors.initials: E
authors.lastname: Vicaut
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D000925:Anticoagulants / Q000008:administration & dosage*; D004562:Electrocardiography; D017984:Enoxaparin / Q000008:administration & dosage*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006493:Heparin / Q000008:administration & dosage*; D006801:Humans; D007275:Injections, Intravenous; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D012008:Recurrence
chemical_list: D000925:Anticoagulants; D017984:Enoxaparin; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D006493:Heparin