Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial

作者：Devereaux, P. J.^*; Duceppe, Emmanuelle; Guyatt, Gordon; Tandon, Vikas; Rodseth, Reitze; Biccard, Bruce M.; Xavier, Denis; Szczeklik, Wojciech; Meyhoff, Christian S.; Vincent, Jessica; Franzosi, Maria Grazia; Srinathan, Sadeesh K.; Erb, Jason; Magloire, Patrick; Neary, John; Rao, Mangala; Rahate, Prashant V.; Chaudhry, Navneet K.; Mayosi, Bongani; de Nadal, Miriam; Iglesias, Pilar Paniagua; Berwanger, Otavio; Villar, Juan Carlos; Botto, Fernando; Eikelboom, John W.; Sessler, Daniel I.

来源：Lancet, 2018, 391(10137): 2325-2334.

DOI：10.1016/S0140-6736(18)30832-8

• ACUTE CORONARY SYNDROMES
• DOUBLE-BLIND
• RIVAROXABAN
• DEFINITION
• ELEVATION
• MORTALITY
• ASPIRIN
• THERAPY
• EVENTS

Background Myocardial injury after non-cardiac surgery (MINS) increases the risk of cardiovascular events and deaths, which anticoagulation therapy could prevent. Dabigatran prevents perioperative venous thromboembolism, but whether this drug can prevent a broader range of vascular complications in patients with MINS is unknown. The MANAGE trial assessed the potential of dabigatran to prevent major vascular complications among such patients. @@@ Methods In this international, randomised, placebo-controlled trial, we recruited patients from 84 hospitals in 19 countries. Eligible patients were aged at least 45 years, had undergone non-cardiac surgery, and were within 35 days of MINS. Patients were randomly assigned (1:1) to receive dabigatran 110 mg orally twice daily or matched placebo for a maximum of 2 years or until termination of the trial and, using a partial 2-by-2 factorial design, patients not taking a proton-pump inhibitor were also randomly assigned (1:1) to omeprazole 20 mg once daily, for which results will be reported elsewhere, or matched placebo to measure its effect on major upper gastrointestinal complications. Research personnel randomised patients through a central 24 h computerised randomisation system using block randomisation, stratified by centre. Patients, health-care providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary efficacy outcome was the occurrence of a major vascular complication, a composite of vascular mortality and non-fatal myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic venous thromboembolism. The primary safety outcome was a composite of life-threatening, major, and critical organ bleeding. Analyses were done according to the intention-to-treat principle. This trial is registered with ClinicalTrials.gov, number NCT01661101. @@@ Findings Between Jan 10, 2013, and July 17, 2017, we randomly assigned 1754 patients to receive dabigatran (n=877) or placebo (n=877); 556 patients were also randomised in the omeprazole partial factorial component. Study drug was permanently discontinued in 401 (46%) of 877 patients allocated to dabigatran and 380 (43%) of 877 patients allocated to placebo. The composite primary efficacy outcome occurred in fewer patients randomised to dabigatran than placebo (97 [11%] of 877 patients assigned to dabigatran vs 133 [15%] of 877 patients assigned to placebo; hazard ratio [HR] 0.72, 95% CI 0.55-0.93; p=0.0115). The primary safety composite outcome occurred in 29 patients (3%) randomised to dabigatran and 31 patients (4%) randomised to placebo (HR 0.92, 95% CI 0.55-1.53; p=0.76). @@@ Interpretation Among patients who had MINS, dabigatran 110 mg twice daily lowered the risk of major vascular complications, with no significant increase in major bleeding. Patients with MINS have a poor prognosis; dabigatran 100 mg twice daily has the potential to help many of the 8 million adults globally who have MINS to reduce their risk of a major vascular complication.

• 出版日期2018-6-9