Circulation, Vol 87, 1524-1530, Copyright © 1993 by American Heart Association
A Meijer, FW Verheugt, CJ Werter, KI Lie, JM van der Pol and MJ van Eenige
BACKGROUND. Successful coronary thrombolysis involves a risk for
reocclusion that cannot be prevented by invasive strategies. Therefore, we
studied the effects of three antithrombotic regimens on the angiographic
and clinical courses after successful thrombolysis. METHODS AND RESULTS.
Patients treated with intravenous thrombolytic therapy followed by
intravenous heparin were eligible when a patent infarct-related artery was
demonstrated at angiography < 48 hours. Three hundred patients were
randomized to either 325 mg aspirin daily or placebo with discontinuation
of heparin or to Coumadin with continuation of heparin until oral
anticoagulation was established (international normalized ratio, 2.8-4.0).
After 3 months, in which conservative treatment was intended, vessel
patency and ventricular function were reassessed in 248 patients.
Reocclusion rates were not significantly different: 25% (23 of 93) with
aspirin, 30% (24 of 81) with Coumadin, and 32% (24 of 74) with placebo.
Reinfarction was seen in 3% of patients on aspirin, in 8% on Coumadin, and
in 11% on placebo (aspirin versus placebo, p < 0.025; other comparison,
p = NS). Revascularization rate was 6% with aspirin, 13% with Coumadin, and
16% with placebo (aspirin versus placebo, p < 0.05; other comparisons, p
= NS). Mortality was 2% and did not differ between groups. An event-free
clinical course was seen in 93% with aspirin, in 82% with Coumadin, and in
76% with placebo (aspirin versus placebo, p < 0.001; aspirin versus
Coumadin, p < 0.05). An event-free course without reocclusion was
observed in 73% with aspirin, in 63% with Coumadin, and in 59% with placebo
(p = NS). An increase of left ventricular ejection fraction was only found
in the aspirin group (4.6%, p < 0.001). CONCLUSIONS. At 3 months after
successful thrombolysis, reocclusion occurred in about 30% of patients,
regardless of the use of antithrombotics. Compared with placebo, aspirin
significantly reduces reinfarction rate and revascularization rate,
improves event-free survival, and better preserves left ventricular
function. The efficacy of Coumadin on these end points appears less than
that of aspirin. The still-high reocclusion rate emphasizes the need for
better antithrombotic therapy in these patients.
ARTICLES
Aspirin versus coumadin in the prevention of reocclusion and recurrent ischemia after successful thrombolysis: a prospective placebo- controlled angiographic study. Results of the APRICOT Study
Free University Hospital, Amsterdam, The Netherlands.
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