Safety and Efficacy of Intravenous Enoxaparin in Elective Percutaneous Coronary Intervention: an International Randomized Evaluation (STEEPLE)
Presented at
The European Society of Cardiology
Hot Line Session 2005
Presented by Dr. Gilles Montalescot
STEEPLE Trial
IV enoxaparin
0.5 mg/kg
n=1070
STEEPLE Trial
Presented at ESC 2005
IV enoxaparin
0.75 mg/kg
n=1228
3528 patients age >18 years undergoing non-emergent single or multi-vessel PCI (performed with a femoral approach)
Randomized
25% female, mean age 64 years, mean follow-up 30 days
GP IIb/IIIa inhibitors were used in 41% of patients, and aspirin in 85%
Drug-eluting stents were used in 57% of patients and multivessel PCI was performed in 16% of patients
Primary Endpoint: Non-CABG related major and minor bleeding by 48 hrs post-PCI
Secondary Endpoint: Percent of patients reaching target anticoagulation levels at the start and end of the procedure; composite of non-CABG major bleed through 48 hrs; all-cause mortality; myocardial infarction; urgent target vessel revascularization at 30 days
Activated clotting time (ACT) – adjusted
IV unfractionated heparin (UFH) regimen
With GP IIb/IIIa (50-70 IU dose): target ACT 200-300
Without GP IIb/IIIa (70-100 IU dose): target ACT 300-350
n=1230
STEEPLE Trial: Primary Endpoint at 48 hours
Analysis of non-CABG major or minor bleeding (%)
Presented at ESC 2005
The primary endpoint of non-CABG major or minor bleeding was lower in those groups treated with enoxaparin
The lower bleeding rate associated with enoxaparin was observed both in the subgroup of patients intended to be treated with GP IIb/IIIa inhibitors, as well as in a per protocol analysis
p=0.014 vs UFH
p=0.052 vs UFH
STEEPLE Trial: Primary Endpoint at 48 hours
Analysis of major bleeding (%)
Presented at ESC 2005
Major bleeding occurred in 1.2% of each of the enoxaparin groups and 2.8% in the UFH group
The primary endpoint of major bleeding was 57% lower in the enoxaparin groups compared with the UFH group
p=0.005 vs UFH
p=0.007 vs UFH
STEEPLE Trial: Primary Endpoint at 48 hours
Analysis of minor bleeding (%)
Presented at ESC 2005
Minor bleeding occurred in 4.9% (0.5 mg/kg) and 5.4% (0.75 mg/kg) in each of the two enoxaparin groups and 5.9% in the UFH group
P=0.315 vs UFH
P=0.530 vs UFH
STEEPLE Trial: Secondary Endpoint
Analysis of patients reaching target anticoagulation levels at the
start and end of procedure (%)
Presented at ESC 2005
The percent of patients reaching target anticoagulation levels at the start and end of the procedure was significantly lower among the UFH treatment group compared with the two enoxaparin treatment groups (78.8%, 91.7% vs 19.7%)
p<0.001 vs UFH
p<0.001 vs UFH
STEEPLE Trial: Secondary Endpoint
Composite endpoint of non-CABG major bleed through 48 hours, all-cause mortality, MI, or urgent target vessel revascularization at 30 days (%)
p=NS
Presented at ESC 2005
The composite secondary endpoint was numerically lower among the two enoxaparin treatment groups compared with the UFH treatment group (7.2%, 7.9% vs 8.4%)
There was no difference in death or MI individually
STEEPLE Trial Summary
Among patients undergoing non-emergent PCI, treatment with reduced dose enoxaparin was associated with lower rates of major or minor bleeding by 48 hours post-PCI compared with treatment with ACT-driven UFH.
Patient enrollment in the enoxaparin 0.5 mg/kg treatment group was discontinued by the data safety monitoring committee near the end of the trial at the objection of the steering committee, due to a difference in mortality between the three groups (p=0.02).
With full 30 day data, neither mortality, MI, nor urgent target vessel revascularization differed between the three groups.
Further investigation is still necessary, but the results from this trial show that the use of enoxaparin at lower doses in the catheterization laboratory may offer a potential safety advantage with lower bleeding events relative to ACT guided UFH.
Presented at ESC 2005