The Medicines Company has reported a presentation of a pooled analysis of 5,800 patients in the EUROMAX and HORIZONS-AMI trials, two international clinical trials comparing Angiomax(R) (bivalirudin) versus heparin with or without glycoprotein IIb/IIIa inhibitors (GP IIb/IIIa) in patients with ST-segment elevation acute myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). EUROMAX and HORIZONS-AMI studies were presented and published individually in September 2008 and October 2013, in The Lancet and The New England Journal of Medicine respectively.
The pre-specified patient-level data from the EUROMAX and HORIZONS-AMI trials were presented today at the American College of Cardiology's (ACC) 63rd Annual Scientific Session in Washington, D.C.
Lead author, presenter and primary investigator of the EUROMAX trial Professor P. Gabriel Steg, MD, of Hopital Bichat in Paris said, "The totality of the findings in this analysis confirm the earlier findings of the EUROMAX and HORIZONS-AMI trials, and support the fact that bivalirudin should remain the preferred anticoagulant of choice for clinicians treating STEMI patients undergoing primary PCI."
The totality of the data in the EUROMAX and HORIZONS-AMI trials of 5,800 STEMI patients undergoing primary PCI showed a significant absolute reduction in cardiac death of 0.9% (2.0% for bivalirudin vs. 2.9% for control; OR 0.70, 95% CI 0.50-0.97, p=0.03); absolute reduction in major non-CABG-related bleeding of 3.6% (4.2% for bivalirudin vs. 7.8% for control; OR 0.53, 95% CI 0.43-0.66, p= < 0.0001); absolute reduction in transfusion of 1.7% (2.1% for bivalirudin vs. 3.8% for control; OR 0.57, 95% CI 0.42-0.77, p=0.0002); and absolute reduction in net adverse clinical events (NACE) of 3.1% (8.8% for bivalirudin vs. 11.9% for control; OR 0.74, 95% CI 0.63-0.86, p= < 0.0001). The analysis also showed an increased risk of stent thrombosis, driven by an increase in acute stent thrombosis absolute risk of 1.0% (1.2% for bivalirudin vs. 0.2% for control; OR 6.04, 95% CI 2.55-14.31, p= < 0.0001). The findings were consistent across all examined subgroups.
"As we had seen in the results of the EUROMAX and HORIZONS-AMI trials when they were first presented and published, this analysis underscores that use of bivalirudin, compared with a combination of heparin and a GP IIb/IIIa inhibitor, is associated with significant absolute reductions in risk for cardiac death and major non-CABG bleeding," said Gregg W. Stone, MD, Professor of Medicine at Columbia University College of Physicians and Surgeons, Director of Cardiovascular Research and Education at the Center for Interventional Vascular therapy at New York-Presbyterian Hospital/Columbia University Medical Center and Co-Director of the Medical Research and Education Division at the Cardiovascular Research Foundation. Dr. Stone is the principal investigator of the HORIZONS-AMI trial.
In the United States, bivalirudin is marketed under the trade name Angiomax and is indicated in patients undergoing PCI with provisional use of GPI and in patients with, or at risk of, heparin-induced thrombocytopenia and thrombosis syndrome (HIT/HITTS) undergoing PCI. In addition, Angiomax is also indicated for use as an anticoagulant in patients with UA undergoing percutaneous transluminal coronary angioplasty (PTCA). Angiomax is intended for use with aspirin. Angiomax is not approved for use in patients with acute coronary syndromes (ACS) not undergoing PCI or PTCA.
In Europe, Angiox currently is indicated as an anticoagulant for adult patients undergoing PCI, including patients with STEMI undergoing primary PCI. Angiox is also indicated for the treatment of adult patients with unstable angina/non-ST segment elevation MI planned for urgent or early intervention.
In clinical trials comparing Angiomax and heparin, the most common adverse reaction for Angiomax was bleeding (28%). Other common adverse reactions were headache, thrombocytopenia and fever. An unexplained fall in blood pressure or hematocrit, or any unexplained symptom, should lead to serious consideration of a hemorrhagic event and cessation of Angiomax administration. Angiomax should be used with caution in patients with disease states associated with an increased risk of bleeding.
In gamma brachytherapy, an increased risk of thrombus formation, including fatal outcomes, has been associated with the use of Angiomax. Angiomax is contraindicated in patients with active major bleeding or hypersensitivity to Angiomax or its components.
Please see full prescribing information for Angiomax, available at http://www.angiomax.com.
About EUROMAX EUROMAX (EUROpean aMbulance Acs angioX trial) was a 2,218 randomized, controlled, open label, international, multicenter study that compared early administration of bivalirudin, which is marketed as Angiox in the European Union, and Angiomax in the US, to heparins with or without glycoprotein inhibitors (GPI). Patients with ST-segment elevation myocardial infarction (STEMI) who were being transported for primary PCI received either bivalirudin or unfractionated or low-molecular-weight heparin with optional GPI (control group). At 30 days, the primary outcome was a composite of death or major bleeding not associated with coronary-artery bypass grafting (CABG), and the principal secondary outcome was a composite of death, reinfarction, or non-CABG major bleeding. Patients who were assigned to the bivalirudin group received a bolus of 0.75 mg per kilogram, followed by an infusion of 1.75 mg per kilogram per hour, which should be continued for at least 4 hours after PCI. The protocol also specified that the dose during the post-PCI interval should be 0.25 mg per kilogram per hour; however, continuation of the higher dose used during PCI was also permitted. Bailout use of a GPI was allowed in the event of giant thrombus or no-reflow.
About HORIZONS-AMI HORIZONS-AMI, co-funded by a grant from The Medicines Company, was the largest study to focus on the appropriate use of anticoagulation medications and stents in patients experiencing STEMI and undergoing primary percutaneous coronary intervention (PCI), commonly known as angioplasty. This landmark trial was a prospective, single-blind, randomized, multi-center study conducted in 11 countries. Patients undergoing angioplasty were randomly assigned to receive either Angiomax (bivalirudin) with provisional use of GPI or heparin plus GPI. Patients enrolled in the HORIZONS-AMI trial also were assigned randomly to receive either TAXUS(R) drug-eluting stents or a bare-metal stent.
The two primary endpoints of the trial were major bleeding and net adverse clinical events, a composite of major adverse cardiovascular events (death, reinfarction, stroke or ischemic target vessel revascularization) and major bleeding at 30 days. The major secondary endpoint was major adverse cardiovascular events at 30 days.