Postprocedural Anticoagulation After Primary Percutaneous Coronary Intervention

BACKGROUND: The RIGHT trial was designed to assess the efficacy and safety of postprocedural anticoagulation (PPA) in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI). OBJECTIVES: The authors aimed to report the prespecified 1-year outcomes. METHODS: RIGHT is an investigator-initiated, multicenter, randomized, double-blind, placebo-controlled, superiority trial conducted in 53 sites across China. Patients with ST-segment elevation myocardial infarction were randomly assigned (1:1) after primary PCI to receive low-dose PPA (enoxaparin, unfractionated heparin, or bivalirudin) or matching placebo for at least 48 hours. Major adverse cardiac events (MACEs) including all-cause death, nonfatal myocardial infarction, nonfatal stroke, stent thrombosis (definite), and urgent revascularization (any vessel), were assessed during a 1-year follow-up. RESULTS: Over a median follow-up of 1.0 year (IQR: 1.0-1.0), MACE data were available for 99.2% of participants. MACEs occurred in 4.2% (63/1,494) of the PPA group and 4.9% (73/1,495) of the placebo group (HR: 0.86; 95% CI: 0.61-1.21), with no between-group difference in major bleeding (1.3% vs 1.5%; HR: 0.87; 95% CI: 0.47-1.62). In the group of enoxaparin vs placebo, we observed reduction of MACEs with enoxaparin (HR: 0.53; 95% CI: 0.30-0.97) with no excess bleeding. Meta-analyses also showed an advantage of enoxaparin over no anticoagulation in reducing MACEs at 30 days (risk ratio: 0.635; 95% CI: 0.399-0.997). CONCLUSIONS: Low-dose PPA after primary PCI was safe but did not reduce ischemic events at the 1-year follow-up. If clinically indicated, our results suggest that enoxaparin may be beneficial and warrants confirmation in future studies. (Comparison of Anticoagulation Prolongation vs. no Anticoagulation in STEMI Patients After Primary PCI [RIGHT]; NCT03664180).