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. 2022 Oct 21;18(9):709-718.
doi: 10.4244/EIJ-D-22-00432.

Pretreatment with heparin in patients with ST-segment elevation myocardial infarction: a report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR)

Oskar Love Emilsson  1 , Sofia Bergman  1   2 , Moman A Mohammad  1   2 , Göran K Olivecrona  1   2 , Matthias Götberg  1   2 , David Erlinge  1   2 , Sasha Koul  1   2
Affiliations

Pretreatment with heparin in patients with ST-segment elevation myocardial infarction: a report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR)

Oskar Love Emilsson et al. EuroIntervention. .

Abstract

Background: Unfractionated heparin (UFH) is frequently administered before percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI).

Aims: The aim of the study was to investigate if pretreatment with UFH prior to arrival at the catheterisation laboratory affects coronary artery occlusion, mortality, and in-hospital major bleeding in patients with STEMI undergoing PCI.

Methods: Patients with a first STEMI event undergoing PCI between 2008 and 2016 were extracted from the Swedish Coronary Angiography and Angioplasty Registry. Risk ratios for UFH pretreatment versus no pretreatment regarding coronary artery occlusion at presentation in the catheterisation laboratory, 30-day mortality, and bleeding were obtained using adjusted Poisson regression models with robust standard errors. Analyses of propensity score (PS)-matched groups were performed to obtain absolute risk differences.

Results: In all, 41,631 patients were included, 16,026 (38%) with and 25,605 (62%) without UFH pretreatment. Adjusted risk ratios were 0.89 (95% confidence interval [CI]: 0.87 to 0.90) for coronary artery occlusion, 0.87 (0.77 to 0.99) for mortality, and 1.01 (0.86 to 1.18) for bleeding. In the PS-matched analyses, the absolute risk differences were -0.087 (-0.074 to -0.099) for coronary artery occlusion, -0.011 (-0.017 to -0.0041) for mortality, and 0 (-0.0052 to 0.0052) for bleeding.

Conclusions: Pretreatment with UFH was associated with a reduction in coronary artery occlusion among patients with STEMI, with a number needed to treat (NNT) of 12, without increasing the risk of major in-hospital bleeding. Regarding mortality, a reduction was found with UFH pretreatment, with an NNT of 94, but this effect was not robust over all sensitivity analyses and residual confounding cannot be excluded.

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Conflict of interest statement

G.O. Olivecrona received consulting fees from Edwards Lifesciences, honoraria from Biotronik, EPS Vascular, and Abbott and participates on the Board of Biosensor CEC BioFreedom STEMI. M. Götberg received consulting fees from Boston Scientific and Medtronic and participates in the EAPCI Fellowship Grant Committee and the Case Review Committee of Boston Scientifc. The other authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1. Flowchart of the study population.
PCI: percutaneous coronary intervention; SCAAR: Swedish Coronary Angiography and Angioplasty Registry; STEMI: ST-segment elevation myocardial infarction
Central illustration
Central illustration. Patient outcomes with versus without heparin pretreatment in patients with ST-segment elevation myocardial infarction undergoing PCI.
A) Flowchart of patients included for analysing occlusion or mortality and bleeding from the Swedish Coronary Angiography and Angioplasty Registry. B) Forest plots with risk ratios, calculated using adjusted Poisson regression as well as PS-matched groups, and absolute risk differences, calculated using PS-matched groups. C) Kaplan-Meier curves for overall survival with 95% confidence intervals (dashed lines) in PS-matched groups with (blue) and without (red) unfractionated heparin. CI: confidence intervals; PCI: percutaneous coronary intervention; PS: propensity score; STEMI: ST-segment elevation myocardial infarction; UFH: unfractionated heparin
Figure 2
Figure 2. Fully adjusted subgroup analyses regarding coronary artery occlusion, mortality, and bleeding (unfractionated heparin pretreatment versus no such treatment).
Subgroups with statistically significant p-values for interaction are presented with filled circles with p-values provided. Subgroups without statistically significant interaction are presented with open circles. Occlusion adjusted for: age, smoking status, sex, year, previous bleeding, CABG, COPD, diabetes, heart failure, hyperlipidaemia, hypertension, kidney failure, heart failure, peripheral vessel disease, stroke, antithrombotic treatment prior to PCI (including: aspirin, clopidogrel, fondaparinux, GPIIb/IIIa-inhibitor, LMWH, prasugrel, thrombolysis, ticagrelor, and warfarin), proximal infarction, tertiary centre, and time from symptom onset to PCI. Mortality and bleeding adjusted for: age, smoking status, sex, year, previous bleeding, CABG, COPD, diabetes, heart failure, hyperlipidaemia, hypertension, kidney failure, heart failure, peripheral vessel disease, stroke, antithrombotic treatment prior to PCI (including: aspirin, clopidogrel, fondaparinux, GPIIb/IIIa-inhibitor, LMWH, prasugrel, thrombolysis, ticagrelor, and warfarin), antithrombotic treatment during PCI (including: aspirin, bivalirudin, clopidogrel, GPIIb/IIIa-inhibitor, heparin, LMWH, prasugrel, and ticagrelor), proximal infarction, tertiary centre, and time from symptom onset to PCI. CABG: coronary artery bypass graft; COPD: chronic obstructive pulmonary disease; GP: glycoprotein; LAD: left anterior descending artery; LCx: left circumflex artery; LMWH: low-molecular-weight heparin; MI: myocardial infarction; PCI: percutaneous coronary intervention; RCA: right coronary artery
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