Reduced Dose of Unfractionated Heparin in Patients Undergoing PCI (ISAR-REACT-3A)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT00735280
Recruitment Status : Completed
First Posted : August 14, 2008
Last Update Posted : January 5, 2012
Information provided by (Responsible Party):
Deutsches Herzzentrum Muenchen

Brief Summary:
The aim of this trial is to evaluate whether a reduction in the heparin dose from 140 to 100 U/kg is associated with a better net clinical outcome in patients undergoing PCI after pretreatment with 600mg clopidogrel

Condition or disease Intervention/treatment Phase
Coronary Artery Disease Drug: unfractionated heparin Phase 4

Detailed Description:
Percutaneous coronary interventions, mostly with implantation of bare-metal or drug-eluting stents, are commonly used to treat patients with coronary artery disease. Various periprocedural adjunct antithrombotic therapies have been investigated and are being used. Unfractionated heparin (UFH) has been the standard adjunctive antithrombin therapy during PCI for more than 25 years. Combined antiplatelet treatment consisting of aspirin and a thienopyridine has significantly reduced early ischaemic events following coronary stenting (1). Thienopyridines act by irreversibly inhibiting the platelet adenosine diphosphate (ADP) P2Y12 receptor. Compared to ticlopidine, clopidogrel has the advantage of a more favourable side effect profile (2) and more rapid onset of action.(3,4) Pretreatment with a loading dose of 300mg clopidogrel improved outcomes (5-7) and is recommended by current guidelines for patients undergoing PCI. (8) More recently, trials have shown that the larger loading dose of 600mg achieves more rapid and more potent inhibition of platelet aggregation than 300 mg do.(9-11) The results of several randomized controlled trials suggest that pretreatment with 600mg clopidogrel might obviate the need for IIb/IIIa inhibitors in a broad spectrum of patients undergoing PCI (12-14) although no formal direct comparison of different clopidogrel doses has been assessed by trials sufficiently powered for clinical endpoints. The Intracoronary Stenting and Antithrombotic Regimen-Rapid Early Action for Coronary Treatment (ISAR-REACT) trial showed that after pretreatment with 600mg clopidogrel for at least 2 hours before the intervention, additional use of abciximab was not associated with any clinically measurable benefit among low-to-intermediate risk patients who underwent PCI.(12) Even in higher risk settings such as small vessel size (14) and the presence of diabetes (13)additional use of abciximab was not associated with a measurable clinical benefit in patients pretreated with 600mg clopidogrel. An important exception is the group of patients with non-ST-segment elevation ACS. In the ISAR-REACT-2 trial that enrolled this category of patients those with an elevated troponin level did benefit from abciximab even after pretreatment with 600mg clopidogrel.(15) The recently completed ISAR-REACT-3 trial compared unfractionated heparin with the direct thrombin inhibitor bivalirudin in biomarker negative patients with stable and unstable angina undergoing contemporary PCI. Bivalirudin did not provide "net clinical benefit" - did not reduce the quadruple endpoint - at 30 days compared to unfractionated heparin. However, there was a significant reduction in bleeding with bivalirudin (16) The heparin dose regimen used in ISAR-REACT-3 diverges from current US practice insofar as the majority of patients received a bolus dose of 140 U/kg with no follow up ACT measurement and no additional heparin doses. Although heparin has been the standard antithrombin therapy in interventional cardiology for decades, its optimal dose is still not known. During the last years there has been a trend towards using lower heparin doses. In most interventional trials in the United States it is now current practice to use a bolus of not more than 100 U/kg. (8) Many interventionalists believe that a dose lower than 140 U/kg is associated with a better clinical outcome. However, no studies have been performed to identify the most appropriate dose of heparin. Since pretreatment with clopidogrel has proven to reduce ischemic events, a heparin dose of 140U/kg might conceivably be too high. A lower dose might prove to be as effective in preventing ischemic endpoints while reducing the risk of bleeding if patients were pretreated with 600mg clopidogrel prior to the intervention. Therefore the aim of this trial is to evaluate whether a reduction in the heparin dose from 140 to 100 U/kg is associated with a better net clinical outcome in patients undergoing PCI after pretreatment with 600mg clopidogrel. The hypothesis to be tested is whether a reduced dose of 100U/kg heparin is superior to the higher dose of 140U/kg used in the ISAR-REACT-3 trial (historical control) regarding the combined incidence of death, myocardial infarction, urgent target vessel revascularization within 30 days and in hospital major bleeding. The ISAR-REACT-3a trial will enroll a patient population with a similar risk profile to that of patients included in ISAR-REACT-3. Biomarker negative patients with stable or unstable angina undergoing PCI will receive a reduced dose heparin bolus of 100U/kg. Results will be compared with the ISAR-REACT-3 trial (historical control). Primary comparison will be with the heparin arm of ISAR-REACT-3 regarding the primary endpoint ("Net clinical benefit", the combined incidence of death, myocardial infarction, urgent target vessel revascularization within 30 days and in hospital major bleeding). A secondary aspect will be the comparison with the historical bivalirudin group of the ISAR-REACT-3 trial.

Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 2505 participants
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Non-randomized, Open-label, Historical Control, Single Group Assignment Trial of a Reduced Dose of Unfractionated Heparin in Patients Undergoing Percutaneous Coronary Interventions
Study Start Date : August 2008
Actual Primary Completion Date : March 2010
Actual Study Completion Date : March 2011

Resource links provided by the National Library of Medicine

Arm Intervention/treatment
Experimental: Reduced dose of unfractionated heparin Drug: unfractionated heparin
bolus of 100 U/kg of unfractionated heparin

Primary Outcome Measures :
  1. The primary outcome measure will be a composite of death, MI, urgent TVR after 30 days or in hospital bleeding (quadruple endpoint, "net clinical benefit"). [ Time Frame: 30 days ]

Secondary Outcome Measures :
  1. Composite of death, MI or urgent TVR (Triple endpoint to assess ischemic complications) [ Time Frame: 30 days ]
  2. Composite of death, MI or TVR [ Time Frame: 1 year after the index procedure ]

Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  1. Patients older than 18 years undergoing a PCI procedure
  2. Pretreatment with 600mg clopidogrel at least 2 hours before the intervention
  3. Informed, written consent by the patient or her/his legally-authorized representative for participation in the study.

Exclusion Criteria:

  1. Recent ST-elevation myocardial infarction within the last 48 hours
  2. Acute coronary syndromes with positive biomarkers (Troponin T > 0.03 μg/L or CK-MB > ULN)
  3. Cardiogenic shock
  4. Malignancies or other comorbid conditions (for example severe liver, renal and pancreatic disease) with life expectancy less than one year or that may result in protocol non-compliance
  5. Active bleeding; bleeding diathesis
  6. History of gastrointestinal or genitourinary bleeding within the last 6 weeks
  7. Presence of diseases which have a high probability of vascular lesions and subsequent bleeding such as active gastric ulcer or active ulcerous colitis
  8. Recent trauma or major surgery in the last month
  9. Ophthalmic surgery or brain surgery in the last month
  10. Retinopathies or vitreous body bleeding in the last month
  11. History of intracranial bleeding or structural abnormalities (for example aneurysm of cerebral arteries)
  12. Suspected aortic dissection; pericarditis and subacute bacterial endocarditis
  13. Patient's refusal to blood transfusion.
  14. Oral anticoagulation therapy with coumarin derivative within the last 7 days
  15. Treatment with UFH within 6 hours unless an ACT is less than 150 sec or low-molecular weight heparin within 8 hours before enrollment
  16. Treatment with bivalirudin within 24 hours before enrollment
  17. Severe uncontrolled hypertension >180/110 mmHg unresponsive to therapy
  18. Planned staged PCI procedure within 30 days from index procedure or prior PCI within the last 30 days.
  19. Relevant hematologic deviations: hemoglobin < 100 g/L, platelet count < 100 x 109 /L.
  20. Glomerular filtration rate (GFR) < 30 ml/min or serum creatinine > 30 mg/L or dependence on renal dialysis.
  21. Known allergy to the study medications: aspirin, clopidogrel, UFH, true anaphylaxis after prior exposure to contrast media.
  22. Known heparin-induced thrombocytopenia (Typ II)
  23. Previous enrollment in this trial.
  24. Pregnancy (present, suspected or planned) or positive pregnancy test.
  25. Spinal, peridural and epidural anesthesia
  26. Patient's inability to fully cooperate with the study protocol.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT00735280

Bad Krozingen, Germany, 79189
Deutsches Herzzentrum München
München, Germany, 81541
Klinikum rechts der Isar der Technischen Universität München
München, Germany, 81675
Sponsors and Collaborators
Deutsches Herzzentrum Muenchen
Study Chair: Adnan Kastrati, MD Deutsches Herzzentrum München
Principal Investigator: Julinda Mehilli, MD Deutsches Herzzentrum München


Publications automatically indexed to this study by Identifier (NCT Number):
Responsible Party: Deutsches Herzzentrum Muenchen Identifier: NCT00735280     History of Changes
Other Study ID Numbers: GE IDE No. A01408
First Posted: August 14, 2008    Key Record Dates
Last Update Posted: January 5, 2012
Last Verified: January 2012

Keywords provided by Deutsches Herzzentrum Muenchen:
Coronary artery disease, stent, heparin

Additional relevant MeSH terms:
Coronary Artery Disease
Myocardial Ischemia
Coronary Disease
Heart Diseases
Cardiovascular Diseases
Arterial Occlusive Diseases
Vascular Diseases
Calcium heparin
Fibrinolytic Agents
Fibrin Modulating Agents
Molecular Mechanisms of Pharmacological Action