Management of Myocardial Injury After Noncardiac Surgery Trial (MANAGE)

This study is currently recruiting participants. (see Contacts and Locations)
Verified July 2014 by Population Health Research Institute
Sponsor:
Information provided by (Responsible Party):
P.J. Devereaux, Population Health Research Institute
ClinicalTrials.gov Identifier:
NCT01661101
First received: August 7, 2012
Last updated: July 31, 2014
Last verified: July 2014

August 7, 2012
July 31, 2014
January 2013
December 2016   (final data collection date for primary outcome measure)
  • Major vascular complication (for Dabigatran) [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: No ]
    A composite of the number of patients suffering vascular mortality, nonfatal myocardial infarction, nonfatal stroke, nonfatal peripheral arterial thrombosis, and nonfatal symptomatic pulmonary embolism.
  • Major upper gastrointestinal complication (for Omeprazole) [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: No ]
    A composite of the number of patients suffering overt gastroduodenal bleeding, overt upper gastrointestinal bleeding of unknown origin, or upper gastrointestinal perforation.
  • Major vascular complication (for Dabigatran) [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: No ]
    A composite of vascular mortality, nonfatal myocardial infarction, nonfatal stroke, nonfatal peripheral arterial thrombosis, and nonfatal symptomatic pulmonary embolism.
  • Major upper gastrointestinal complication (for Omeprazole) [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: No ]
    A composite of overt gastroduodenal bleeding, overt upper gastrointestinal bleeding of unknown origin, symptomatic gastroduodenal ulcer, gastrointestinal pain with underlying multiple gastroduodenal erosions, or upper gastrointestinal perforation
Complete list of historical versions of study NCT01661101 on ClinicalTrials.gov Archive Site
  • Individual secondary outcomes for Dabigatran [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: No ]
    The number of patients suffering all-cause mortality, vascular mortality, myocardial infarction, stroke, cardiac revascularization procedure, symptomatic venous thromboembolism (i.e., symptomatic pulmonary embolism or symptomatic deep venous thrombosis), amputation, peripheral arterial thrombosis, and rehospitalization for vascular reasons.
  • Upper gastrointestinal complication for Omeprazole [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: No ]
    A composite of the number of patients suffering overt gastroduodenal bleeding, overt upper gastrointestinal bleeding of unknown origin, symptomatic gastroduodenal ulcer, gastrointestinal pain with underlying multiple gastroduodenal erosions, or upper gastrointestinal perforation.
  • Major vascular complication for Omeprazole [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: No ]
    A composite of the number of patients suffering vascular mortality, nonfatal myocardial infarction, nonfatal stroke, nonfatal peripheral arterial thrombosis and nonfatal symptomatic pulmonary embolism.
  • Individual secondary outcomes for Omeprazole [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: No ]
    The number of patients suffering overt gastroduodenal bleeding, overt esophageal bleeding, overt upper gastrointestinal bleeding of unknown origin, symptomatic gastroduodenal ulcer, gastrointestinal pain with underlying multiple gastroduodenal erosions, upper gastrointestinal perforation, and bleeding of assumed occult gastrointestinal origin with a documented drop in hemoglobin of ≥ 3.0 g/dL.
  • Safety outcomes for Dabigatran [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: Yes ]
    The number of patients suffering life-threatening bleeding, major bleeding, intracranial bleeding, minor bleeding, significant lower gastrointestinal bleeding, non-significant lower gastrointestinal bleeding, and dyspepsia.
  • Safety outcomes for Omeprazole [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: Yes ]
    The number of patients suffering Clostridium difficile-associated diarrhea, diarrhea, community-acquired pneumonia, and fractures.
  • Individual secondary outcomes for Dabigatran [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: No ]
    All-cause mortality, vascular mortality, myocardial infarction, stroke, cardiac revascularization procedure, symptomatic venous thromboembolism (i.e., symptomatic pulmonary embolism or symptomatic deep venous thrombosis), amputation, peripheral arterial thrombosis, and rehospitalization for vascular reasons.
  • Major vascular complication (for Omeprazole) [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: No ]
    A composite of vascular mortality, nonfatal myocardial infarction, nonfatal stroke, nonfatal peripheral arterial thrombosis and nonfatal symptomatic pulmonary embolism.
  • Individual secondary outcomes for Omeprazole [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: No ]
    Overt gastroduodenal bleeding, overt esophageal bleeding, overt upper gastrointestinal bleeding of unknown origin, symptomatic gastroduodenal ulcer, gastrointestinal pain with underlying multiple gastroduodenal erosions, upper gastrointestinal perforation, and bleeding of assumed occult gastrointestinal origin with a documented drop in hemoglobin of ≥3.0 g/dL.
  • Safety outcomes for Dabigatran [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: Yes ]
    Life-threatening bleeding, major bleeding, intracranial bleeding, minor bleeding, significant lower gastrointestinal bleeding, non-significant lower gastrointestinal bleeding, and dyspepsia.
  • Safety outcomes for Omeprazole [ Time Frame: Average of 1 year follow-up ] [ Designated as safety issue: Yes ]
    Clostridium difficile-associated diarrhea, diarrhea, community-acquired pneumonia, and fractures.
Not Provided
Not Provided
 
Management of Myocardial Injury After Noncardiac Surgery Trial
A Large, International, Randomized, Placebo-controlled Trial to Assess the Impact of Dabigatran (a Direct Thrombin Inhibitor) and Omeprazole (a Proton-pump Inhibitor) in Patients Suffering Myocardial Injury After Noncardiac Surgery

Patients who have myocardial injury after noncardiac surgery are at a higher risk of dying than those who do not. One in 10 patients with myocardial injury will die within 30 days of surgery. This risk of death exists up to one year after myocardial injury. There are currently no treatments or guidelines available for heart injury after surgery, but there is evidence that taking a blood-thinner can prevent some of the deaths, both in the short and long-term. The purpose of this trial is to test the effect of two drugs (dabigatran and omeprazole) that may prevent mortality, major cardiovascular complications and major upper gastrointestinal bleeding in patients who have had myocardial injury after noncardiac surgery.

Myocardial injury is the most common major vascular complication after noncardiac surgery. Worldwide approximately 10 million adults annually suffer a perioperative myocardial injury. This figure for perioperative myocardial injury represents 15-20% of all cases of myocardial infarction in all settings. Myocardial injury after noncardiac surgery carries a poor prognosis and is an independent predictor of 30-day and 1-year mortality.

Myocardial injury after noncardiac surgery (MINS) differs from non-operative myocardial infarction in two ways; it has a poorer prognosis (patients suffering MINS are 2 times more likely to die within 30 days compared to non-operative myocardial infarction in the emergency room) and paradoxically its treatment is less intensive. This difference in the intensity of treatment is likely influenced by several factors including: (1) a majority of patients suffering MINS do not experience ischemic symptoms, potentially influencing physicians' perception of the severity of the event; (2) there is debate as to the pathophysiology of MINS (although emerging evidence does suggest that coronary arterial thrombosis is an important mechanism of MINS); and (3) no randomized controlled trial (RCT) has evaluated an intervention to manage MINS, and hence physicians are uncertain about the risk-benefit ratio of potential interventions (e.g., interventions that are effective in the management of non-operative myocardial infarction). From a human and economic perspective, it is a tragedy that some patients undergoing noncardiac surgery for important reasons (e.g., to obtain a cure of their cancer or to become mobile after a new prosthetic joint) fail to obtain these benefits, because they suffer MINS that ultimately takes their life. There is an urgent need for clinical trials to identify effective therapies to improve the outcomes of patients suffering MINS.

There exists promising laboratory, autopsy, imaging, operative, and non-operative data suggesting that patients suffering MINS will benefit from anticoagulant therapy. Dabigatran (a direct thrombin inhibitor) warrants evaluation in the management of MINS. The major limitation of anticoagulation therapy is bleeding, and gastrointestinal bleeding represents a substantial proportion of these complications. Gastrointestinal bleeding is important in its own right, but also because it leads to cessation of anticoagulant therapy which may lead to breakthrough myocardial infarction. Omeprazole (a proton pump inhibitor) is efficacious in preventing upper gastrointestinal bleeding in patients with coronary artery disease who are taking dual antiplatelet therapy, and may benefit patients receiving anticoagulation therapy after suffering MINS.

We will undertake a large international RCT to determine the impact of dabigatran in patients who have suffered MINS. We will use a partial factorial design (for patients not taking a proton pump inhibitor) to determine the impact of omeprazole in this setting. We call this RCT the Management of myocardial injury After NoncArdiac surGEry (MANAGE) Trial.

Interventional
Phase 3
Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Factorial Assignment
Masking: Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor)
Primary Purpose: Treatment
Myocardial Injury After Noncardiac Surgery (MINS)
  • Drug: Dabigatran
    Dabigatran 110 mg taken twice daily
    Other Name: Pradaxa
  • Drug: Placebo (for Dabigatran)
    Dabigatran placebo taken twice daily
  • Drug: Omeprazole
    Omeprazole 20 mg capsule taken once daily
    Other Names:
    • Prilosec
    • Zegerid
  • Drug: Placebo (for Omeprazole)
    Omeprazole placebo taken once daily
  • Experimental: Dabigatran
    Dabigatran 110 mg capsule taken twice daily
    Intervention: Drug: Dabigatran
  • Experimental: Omeprazole
    Omeprazole 20 mg capsule taken once daily
    Intervention: Drug: Omeprazole
  • Placebo Comparator: Placebo (dabigatran)
    Dabigatran placebo taken twice daily
    Intervention: Drug: Placebo (for Dabigatran)
  • Placebo Comparator: Placebo (omeprazole)
    Omeprazole placebo taken once daily
    Intervention: Drug: Placebo (for Omeprazole)
Not Provided

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Recruiting
3200
December 2016
December 2016   (final data collection date for primary outcome measure)

Inclusion Criteria:

Patients are eligible if they:

  1. have undergone noncardiac surgery;
  2. are ≥45 years of age;
  3. have suffered MINS based upon fulfilling one of the following criteria: A. Elevated troponin or CK-MB measurement with one or more of the following defining features i. ischemic signs or symptoms (i.e., chest, arm, neck, or jaw discomfort; shortness of breath, pulmonary edema); ii. development of pathologic Q waves present in any two contiguous leads that are ≥30 milliseconds; iii. electrocardiogram (ECG) changes indicative of ischemia (i.e., ST segment elevation [≥2 mm in leads V1, V2, or V3 OR ≥1 mm in the other leads], ST segment depression [≥1 mm], OR symmetric inversion of T waves ≥1 mm) in at least two contiguous leads; iv. new LBBB; or v. new or presumed new cardiac wall motion abnormality on echocardiography or new or presumed new fixed defect on radionuclide imaging B. Elevated troponin measurement after surgery with no alternative explanation (e.g., pulmonary embolism, sepsis) to myocardial injury; AND
  4. provide written informed consent to participate while still in hospital after their index surgery and within 5 days of suffering their MINS.

Exclusion Criteria:

Patients meeting any of the following criteria will be excluded:

  1. hypersensitivity or known allergy to dabigatran;
  2. history of intracranial, intraocular, or spinal bleeding;
  3. hemorrhagic disorder or bleeding diathesis;
  4. known hepatic impairment or liver disease expected to have an impact on survival;
  5. condition that requires therapeutic dose anticoagulation (e.g., prosthetic heart valve, venous thromboembolism, atrial fibrillation);
  6. currently using or plan to initiate rifampicin, cyclosporine, itraconazole, tacrolimus, ketoconazole, or dronedarone;
  7. women who are pregnant, breastfeeding, or of childbearing potential who refuse to use a medically acceptable form of contraception throughout the study;
  8. investigator considers the patient unreliable regarding requirement for study follow-up or study drug compliance; OR
  9. previously enrolled in the MANAGE Trial.

Also excluded will be patients in whom any of the following criteria persist beyond 5 days of their suffering MINS:

  1. the attending surgeon believes it is not safe to initiate therapeutic dose anticoagulation therapy;
  2. the attending physician believes ASA, intermittent pneumatic compression, or elastic stockings are not sufficient for venous thromboembolism (VTE) prophylaxis and that the patient requires a prophylactic-dose anticoagulant;
  3. the patient has an indwelling epidural or spinal catheter that cannot be removed, or the first dose of dabigatran will occur within 4 hours of epidural catheter removal; OR
  4. estimated glomerular filtration rate (eGFR) <35 ml/min as estimated by calculated creatinine clearance.
  5. it is expected that the patient will undergo cardiac catheterization for MINS.

Exclusion Criteria Specific to Patients in the Omeprazole Factorial Component of the Trial:

Patients meeting any of the following criteria:

  1. hypersensitivity or known allergy to omeprazole;
  2. requirement for a proton pump inhibitor, an H2-receptor antagonist, sucralfate, atazanavir, clopidogrel, or misoprostol;
  3. esophageal or gastric variceal disease; OR
  4. patient declines participation in the omeprazole arm of MANAGE.
Both
45 Years and older
No
Contact: Jessica Vincent, M.Sc. 905-527-4322 ext 40635
Contact: MANAGE Project Office manage@phri.ca
United States,   Canada,   Denmark,   Germany,   Philippines,   South Africa,   Spain
 
NCT01661101
1160.143, 2011-006056-37
Yes
P.J. Devereaux, Population Health Research Institute
Population Health Research Institute
Not Provided
Principal Investigator: P.J. Devereaux, MD, PhD Population Health Research Institute
Population Health Research Institute
July 2014

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP