Adjunctive antithrombotic therapy with primary percutaneous coronary intervention in ST elevation myocardial infarction: ATOLL in perspective.

Abstract

This commentary refers to ‘Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: the international randomised open-label ATOLL trial’, by G. Montalescot et al. , doi:10.1016/S0140-6736(11)60876-3, published in The Lancet 2011;378:693–703. \n\nAn ATOLL is a circular-shaped coral reef surrounding a lagoon providing protection to the marine life. The Tuvalu Atoll is 3–5 m above sea level and is the country most threatened by climate change.\n\n![Graphic][1] \n\nTuvalu Atoll \n\nThe prevalence of myocardial infarction (MI) is falling, related to better primary prevention and pharmacological control of risk factors.1,2 Mortality is also falling as reperfusion therapies are instituted in a timely manner3 and, in some countries, in-hospital mortality following primary percutaneous coronary intervention (PCI) is ∼4%.4 These achievements are a credit to the investigators who developed the evidence base and to those who have implemented the knowledge and developed systems of care. However, there are further improvements that need to be made.\n\nFor patients with ST elevation myocardial infarction (STEMI), timely reperfusion is of the utmost importance, and it remains bewildering and concerning as to why ∼40% of eligible patients still do not receive any form of reperfusion therapy and, when they do, they often receive it late.5\n\nAdjunctive antiplatelet and anticoagulant therapy have improved outcomes with fibrinolysis5 and, when fibrinolysis is coupled with PCI, enoxaparin reduces death or MI at 30 days compared with unfractionated heparin (UFH); 13.0% vs. 16.7% UFH, relative risk (RR) 0.77, P = 0.013.\n\nAntithrombotic therapy with primary PCI is necessary to decrease thrombotic complications of death/MI and stent thrombosis, but for adjunctive antiplatelet and anticoagulant therapy there is a smaller evidence base than with fibrinolysis ( Figure\xa01 ).\n\n\n\nFigure 1 \n( A ) Efficacy of anticoagulants and antiplatelet agents in primary percutaneous coronary intervention. According to prespecified ischaemic …\n\n [1]: pending:yes