LV Thrombus After Acute AMI: A Randomized Controlled Trial
Study Details
Study Description
Brief Summary
Left Ventricular (LV) thrombus formation is witnessed in at least 10% of patients with ST segment elevation myocardial infarction (STEMI). It is a feared complication since it might increase the risk of thrombo-embolic events, including stroke. Guidelines recommend vitamin K antagonist treatment in these patients. However patients with STEMI nowadays undergo primary percutaneous coronary intervention (PCI) with coronary stent placement and consequently require dual anti-platelet therapy (ascal and P2Y12 inhibitors) to prevent stent thrombosis. Consequently, STEMI patients with LV thrombus are currently treated with triple antithrombotic therapy (aspirin, P2Y12 inhibitors, e.g. clopidogrel (75 mg/d) and vitamin K antagonist). Patients treated with triple antithrombotic therapy are subject to a strongly increased bleeding risk with a yearly incidence of 3.7% for dual anti-platelet therapy as compared to 12% for triple antithrombotic therapy. About 10% of these bleedings are cerebral. The mortality of such haemorrhagic strokes is 25%. A recent retrospective analysis did not show any beneficial effects of addition of vitamin K antagonist to dual anti-platelet therapy to prevent stroke. If vitamin K antagonist-therapy could be omitted, morbidity and mortality due to post-PCI bleedings will decrease. Therefore, a randomized trial is warranted to address this issue.
Design: A multicenter, prospective, randomized, two non-inferiority trial. The objective of the study is to determine in a randomized fashion the risks and benefits of the addition of vitamin K antagonists to dual anti-platelet therapy or dual anti-platelet therapy in patients with PCI-treated STEMI and LV thrombus formation on baseline echocardiography or baseline Magnetic Resonance Imaging (MRI).
Condition or Disease | Intervention/Treatment | Phase |
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N/A |
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
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Active Comparator: Triple antithrombotic therapy Treatment with aspirin, P2Y12 inhibitors and vitamin K antagonist. |
Drug: Absence of Acenocoumarol
Dual anti-platelet therapy without the addition of Acenocoumarol.
|
No Intervention: Triple anti-thrombotic therapy Treatment with aspirin, P2Y12 inhibitors and vitamin K antagonist. |
Outcome Measures
Primary Outcome Measures
- The proportions of patients with new cerebral micro-infarcts at 6 months relative to baseline measured by MRI. [6 months relative to baseline]
Primary outcome is defined as the proportions of patients with new cerebral micro-infarcts at 6 months relative to baseline measured by Magnetic Resonance Imaging.
Secondary Outcome Measures
- The presence of new cerebral micro-bleeds assessed by MRI [At 6 months and 12 months relative to baseline]
- Occurrence of major and minor bleeding [At 6 and 12 months relative to baseline]
- Neurological status [At 6 and 12 months relative to baseline]
- Quality of life. [At 6 and 12 months relative to baseline]
- Composite of vascular death, recurrent myocardial infarction, stroke or systemic embolism [At 6 and 12 months relative to baseline]
Eligibility Criteria
Criteria
Inclusion Criteria:
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Suspected Left Ventricular thrombus on echocardiography or routine Magnetic Resonance Imaging
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Ongoing treatment with dual antiplatelet therapy according to ESC/ACC-AHA guidelines at the time of randomization.
Exclusion Criteria:
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Younger than 18
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Clinically or hemodynamically unstable
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Treatment with vitamin K antagonist prior to PCI or other expected indication for vitamin K antagonist treatment (e.g. atrium fibrillation) within the next 6 months
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Previous stroke or transient ischemic attack
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Scheduled for major surgery (including Coronary Artery Bypass Grafting) during the course of the study
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Active bleeding or high risk for bleeding contraindicating treatment with vitamin K antagonists
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Contra-indication for vitamin K antagonist treatment
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Chronic treatment with NSAIDs or COX-2 inhibitors for more than 4 days per week anticipated to continue during the study
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Congenital cardiac disease
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Presence of supraventricular or ventricular arrhythmias
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Expected candidate for ICD implantation with the next 6 months
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Severe renal impairment (estimated CrCl calculated by Cockcroft-Gault equation 5 30mL/min)
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Known or symptomatic brain disease (such as brain tumor)
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Women who are pregnant.
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Any contraindication for Contrast-Enhanced Magnetic Resonance Imaging (such as pacemaker, cerebrovascular clips, known contrast allergy, claustrophobia)
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Follow-up impossible (for example no fixed abode)
Contacts and Locations
Locations
Site | City | State | Country | Postal Code | |
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1 | Academic Medical Center | Amsterdam | Netherlands | 1105 AZ |
Sponsors and Collaborators
- Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)
- VU University of Amsterdam
- Erasmus Medical Center
Investigators
None specified.Study Documents (Full-Text)
None provided.More Information
Publications
None provided.- 2011-004265-32