Comparison of Anticoagulation Prolongation vs. no Anticoagulation in STEMI Patients After Primary PCI (RIGHT)

Randomized Comparison of Anticoagulation After Primary Percutaneous Coronary Intervention Using Enoxaparin, ACT Guided Unfractionated Heparin or Bivalirudin Prolongation vs. no Anticoagulation To Improve Clinical Outcome

The RIGHT study is a large randomized study dedicated to post-PPCI anticoagulation in STEMI patients. The investigators propose to evaluate the clinical efficacy and safety of anticoagulation prolonged for at least 48 hours after the procedure vs. no prolongation of anticoagulation after procedure in patients with STEMI treated with bivalirudin during PPCI (primary hypothesis). When allocated to anticoagulation prolongation by randomization, the subject will be assigned to UFH, enoxaparin or bivalirudin (same regimen allocated by centre) for at least 48 hours after PPCI. The results from this study are expected to provide guidance on the risk/benefit of post-procedural anticoagulation in patients with STEMI.

Study Overview

• Status: Completed
• Conditions: STEMI - ST Elevation Myocardial Infarction
• Intervention / Treatment: Drug: Bivalirudin; Drug: Enoxaparin; Drug: Unfractionated heparin; Drug: Bivalirudin placebo; Drug: Enoxaparin placebo syringe; Drug: Unfractionated heparin placebo

Detailed Description

A minor change of time of randomization after prolongation of bivalirudin infusion at PCI dose up to 4 hours on protocol at September 19,2018. Reasons: a minor change concerning the timing of randomization considering the current local practice in some centers that use the 4 hour infusion of bivalirudin just after PCI. It remains in agreement with the current international guidelines and with the drug label in China. There is no change in drugs used and doses of these drugs once the randomization occurs.

• Study Type: Interventional
• Enrollment (Actual): 2989
• Phase: Phase 4

Contacts and Locations

Study Locations

• China
  • Beijing, China, 100029
    • Beijing Anzhen Hospital, Capital Medical University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age ≥18 years old
• STEMI with PPCI of culprit lesion
• Bivalirudin therapy during PPCI
• Signed informed consent form

Exclusion Criteria:

• Patients with a formal indication for anticoagulation after PPCI (e.g. atrial fibrillation, left-ventricular thrombus, intra-aortic balloon pump, pulmonary embolism, mechanical heart valve)
• Patients with any indication for chronic anticoagulation
• Patient with previous lytic treatment
• Patient with previous coronary artery bypass graft surgery
• Cardiogenic shock, malignant ventricular arrhythmia, or mechanical complications
• Any anticoagulation other than bivalirudin started after the procedure before randomization
• Estimated body weight of >120 kg or <45kg
• BP ≥180/110mmHg at randomization
• Any bleeding diathesis or severe hematologic disease or history of intracerebral mass, aneurysm, arteriovenous malformation, recent (<6months) ischemic stroke or TIA, recent (<6months) intracranial hemorrhage or, gastrointestinal or genitourinary bleeding within the past 2 weeks
• History of heparin-induced thrombocytopenia
• Suspected acute aortic dissection (AAD)
• Major surgery within 1 month
• A planned elective surgical procedure that would necessitate an interruption in treatment with P2Y12 inhibitors in the next 6 months after enrollment
• Known PLT≤100×109 or HGB≤10g/L
• Known transaminase >3-fold ULN, or CCr<30ml/min
• Known allergy to any study drug
• Pregnancy or lactation
• Noncardiac coexisting conditions that could limit life expectancy to less than 1 year
• Current participation in an investigational drug or device trial

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: anticoagulation	Drug: Bivalirudin; IV infusion of 0.2 mg/kg/h (low-rate infusion) for at least 48h after the procedure or until discharge from CCU if it occurs later; Drug: Enoxaparin; 40mg/d s.c.for at least 48h after the procedure or until discharge from CCU if it occurs later; Drug: Unfractionated heparin; IV infusion of 10 U/kg/h (maximum 1000 U) initially, adjusted to maintain ACT between 150 and 220 seconds for at least 48h after the procedure or until discharge from CCU if it occurs later
Placebo Comparator: No anticoagulation	Drug: Bivalirudin placebo; Matching placebo IV infusion for at least 48h after the procedure or until discharge from CCU if it occurs later; Drug: Enoxaparin placebo syringe; Placebo syringe will be only prepared by a designated unblended medical professional on site. Placebo syringe will be presented in identical containers as a clear, colorless, sterile liquid of saline.Subcutaneous injection once a day for at least 48 hours after the procedure or until discharge from CCU if it occurs later.; Drug: Unfractionated heparin placebo; Matching placebo IV infusion for at least 48h after the procedure or until discharge from CCU if it occurs later.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Primary efficacy endpoint - number of event of a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, stent thrombosis (definite) or urgent revascularization (any vessel)	The number of event of a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, stent thrombosis (definite) or urgent revascularization (any vessel) within 30 days after randomization	30 days
Primary safety endpoint - The number of event of major bleeding	The number of event of major bleeding (BARC 3 to 5) within 30 days after randomization	30 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Secondary ischemic endpoints - The number of event of a composite of all-cause death, non-fatal myocardial infarction, or non-fatal stroke	The number of event of a composite of all-cause death, non-fatal myocardial infarction, or non-fatal stroke within 30 days after randomization	30 days
Secondary ischemic endpoints - The number of event of a composite of all-cause death or non-fatal myocardial infarction	The number of event of a composite of all-cause death or non-fatal myocardial infarction within 30 days after randomization	30 days
Secondary ischemic endpoints - The number of cardiovascular death events	The number of cardiovascular death event within 30 days after randomization	30 days
Secondary ischemic endpoints - The number of stent thrombosis (ARC definite) events	The number of stent thrombosis (ARC definite) event within 30 days after randomization	30 days
Secondary safety endpoints - The number of bleeding events (TIMI, STEEPLE and GUSTO definition)	The number of bleeding events (TIMI, STEEPLE and GUSTO definition) within 30 days after randomization To demonstrate that post-procedure anticoagulation with UFH, enoxaparin or bivalirudin as compared to their placebo is associated to lower rate of the composite endpoint of major bleeding according to TIMI, STEEPLE and GUSTO definitions within the first 30 days after randomization.	30 days
Secondary safety endpoints - The number of thrombocytopenia events	The number of thrombocytopenia events within 30 days after randomization To demonstrate superiority of a strategy of post-procedure anticoagulation with UFH, enoxaparin or bivalirudin as compared to their placebo by the time from randomization to the first occurrence of any event of the Thrombocytopenia endpoint over 30 days of follow-up.	30 days

Collaborators and Investigators

• Sponsor: Beijing Anzhen Hospital
• Collaborators: Chinese Academy of Medical Sciences, Fuwai Hospital; ACTION Study Group (Pitié-Salpêtrière Hospital), Paris, France

Publications and helpful links

General Publications

• Yan Y, Wang X, Guo J, Li Y, Ai H, Gong W, Que B, Zhen L, Lu J, Ma C, Montalescot G, Nie S. Rationale and design of the RIGHT trial: A multicenter, randomized, double-blind, placebo-controlled trial of anticoagulation prolongation versus no anticoagulation after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Am Heart J. 2020 Sep;227:19-30. doi: 10.1016/j.ahj.2020.06.005. Epub 2020 Jun 20.

Study record dates

Study Major Dates

• Study Start (Actual): January 11, 2019
• Primary Completion (Actual): November 23, 2022
• Study Completion (Actual): November 23, 2022

Study Registration Dates

• First Submitted: August 27, 2018
• First Submitted That Met QC Criteria: September 7, 2018
• First Posted (Actual): September 10, 2018

Study Record Updates

• Last Update Posted (Actual): May 3, 2023
• Last Update Submitted That Met QC Criteria: April 30, 2023
• Last Verified: April 1, 2023

More Information

Terms related to this study

• Keywords: STEMI; anticoagulantion; post-procedure
• Additional Relevant MeSH Terms: Ischemia; Pathologic Processes; Necrosis; Myocardial Ischemia; Heart Diseases; Cardiovascular Diseases; Vascular Diseases; Myocardial Infarction; Infarction; ST Elevation Myocardial Infarction; Molecular Mechanisms of Pharmacological Action; Enzyme Inhibitors; Fibrinolytic Agents; Fibrin Modulating Agents; Protease Inhibitors; Antithrombins; Serine Proteinase Inhibitors; Anticoagulants; Heparin; Bivalirudin; Enoxaparin; Calcium heparin; Enoxaparin sodium; Hirudins
• Other Study ID Numbers: 2018024X; BJUHFRIGHT201802 (Other Identifier: Beijing United Heart Foundation)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No