MICHELANGELO OASIS-6 : Fondaparinux in ST Elevation Myocardial Infarction

• Death or recurrent myocardial infarction [ Time Frame: up to day 30 ] [ Designated as safety issue: No ]
  the first occurrence of any component of death (all-cause mortality) or recurrent myocardial infarction
• Severe hemorrhage [ Time Frame: up to Day 9 ] [ Designated as safety issue: Yes ]
  Severe hemorrhage (modified TIMI criteria)

• Death or recurrent myocardial infarction [ Time Frame: up to Day 9, 90 and 180 ] [ Designated as safety issue: No ]
  The first occurrence of any component of the composite of death (all-cause mortality) or recurrent myocardial infarction
• Death, recurrent myocardial infarction or refractory ischemia [ Time Frame: up to Day 9, 30, 90 and 180 ] [ Designated as safety issue: No ]
  The first occurrence of any component of the composite of death (all-cause mortality), recurrent myocardial infarction or refractory ischemia

The purpose of this research study is to determine the efficacy and safety of fondaparinux (Arixtra) in preventing death and repeat heart attacks and their complications.

This is a randomized, double blind, controlled, parallel group, multi-center, multinational study of fondaparinux vs. control in patients with STEMI randomized within 24 hours of the onset of symptoms. Patients with confirmed STEMI were assigned into one of the following strata, based on local preference: Stratum 1: No indication for UFH; it is generally accepted that patients receiving streptokinase or those not receiving a thrombolytic agent were assigned to this stratum. Stratum 2: Indication for UFH; it is generally accepted that patients receiving a fibrin-specific agent (such as alteplase, reteplase or tenecteplase) or those undergoing primary PCI were assigned to this stratum. Patients who were ineligible for fibrinolysis (e.g. because of late presentation or absolute contra-indication for reperfusion therapy) may fall into either stratum 1 or stratum 2 at investigator's discretion. Following allocation to one of the strata, patients were randomized to fondaparinux or control treatment. Control treatment was dependent on whether the patient was assigned to stratum 1 or stratum 2: Stratum 1: fondaparinux sc* versus fondaparinux-placebo sc for 8 days or until hospital discharge, whichever was earlier. Stratum 2: fondaparinux sc* for 8 days or until hospital discharge, whichever was earlier and UFH-placebo for 24 to 48 hrs (or single bolus injection immediately prior to procedure in case of primary PCI) versus UFH for 24 to 48 hrs (or single bolus injection immediately prior to procedure in case of primary PCI) and fondaparinux-placebo for 8 days or until hospital discharge, whichever was earlier. (*First dose intravenous bolus) Patients were followed up for 6 months

• Myocardial Infarction
• ST-elevation Myocardial Infarction
• Acute Coronary Syndrome
• Acute Myocardial Infarction

• Drug: Fondaparinux - UFH indicated
  2.5mg od, sc (1st dose IV) x 8 days or discharge + UFH-placebo IV bolus x 24-48 hr infusion
• Other: Control - UFH not indicated
  Fondaparinux-placebo od, sc (1st dose IV) x 8 days or discharge
• Drug: fondaparinux - UFH not indicated
  2.5mg od, sc (1st dose IV) x 8 days or discharge
• Drug: Control - UFH
  UFH IV bolus +12 IU/kg/hr infusion x 24-48 hr + fondaparinux-placebo od, sc (1st dose IV) x 8 days or discharge

• Experimental: Fondaparinux - UFH not indicated
  Subjects with no indication for UFH therapy: 2.5mg od, sc, (1st dose IV) x 8 days or discharge
  Intervention: Drug: fondaparinux - UFH not indicated
• Placebo Comparator: Control - UFH not indicated
  Subjects with no indication for UFH therapy: Fondaparinux-placebo od, sc (1st dose IV) x 8 days or discharge
  Intervention: Other: Control - UFH not indicated
• Experimental: Fondaparinux - UFH indicated
  Subjects indicated for UFH: 2.5mg od, sc (1st dose IV) x 8 days or discharge + UFH-placebo IV bolus + 24-48 hr infusion
  Intervention: Drug: Fondaparinux - UFH indicated
• Active Comparator: Control - unfractionated heparin
  Subjects indicated for UFH: UFH IV bolus +12 IU/kg/hr infusion x 24-48 hr + fondaparinux-placebo od, sc (1st dose IV) x 8 days or discharge
  Intervention: Drug: Control - UFH

• Yusuf S, Mehta SR, Chrolavicius S, Afzal R, Pogue J, Granger CB, Budaj A, Peters RJ, Bassand JP, Wallentin L, Joyner C, Fox KA; OASIS-6 Trial Group. Effects of fondaparinux on mortality and reinfarction in patients with acute ST-segment elevation myocardial infarction: the OASIS-6 randomized trial. JAMA. 2006 Apr 5;295(13):1519-30. Epub 2006 Mar 14.
• Díaz R, Goyal A, Mehta SR, Afzal R, Xavier D, Pais P, Chrolavicius S, Zhu J, Kazmi K, Liu L, Budaj A, Zubaid M, Avezum A, Ruda M, Yusuf S. Glucose-insulin-potassium therapy in patients with ST-segment elevation myocardial infarction. JAMA. 2007 Nov 28;298(20):2399-405.

Inclusion Criteria:

• Patients presenting or admitted to hospital with: a) signs and symptoms of acute myocardial infarction (AMI) b) able to randomize within 24 hours from symptom onset, and c) definite ECG changes indicating STEMI: persistent ST-elevation (greater than or equal to 0.2 mV in two contiguous precordial leads, or greater than or equal to 0.1 mV in at least two limb leads), or new left bundle branch block, or ECG changes indicating true posterior MI
• written informed consent

Exclusion criteria:

• age < 21 years
• currently receiving an oral anticoagulant agent with an INR > 1.8
• any contraindication to anticoagulation therapy such as high risk of bleeding or active bleeding
• hemorrhagic stroke within the last 12 months
• indication for anticoagulation other than acute coronary syndrome (ACS)
• pregnant women or women of child-bearing potential who are not using an effective method of contraception
• co-morbid condition with a life expectancy < 6 months
• prior enrollment in one of the fondaparinux ACS trials
• participation in another pharmacotherapeutic study within the prior 30 days or currently receiving an experimental pharmacological agent
• known allergy to heparin or fondaparinux