Myocardial Injury After Noncardiac Surgery (MINS) | Management of Myocardial Injury After Noncardiac Surgery Trial
Myocardial Injury After Noncardiac Surgery (MINS) research study
What is the primary objective of this study?
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.
Who is eligible to participate?
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 within 35 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 35 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.
Which medical condition, disease, disorder, syndrome, illness, or injury is researched?
Myocardial Injury After Noncardiac Surgery (MINS)
Interventions can include giving participants drugs, medical devices, procedures, vaccines, and other products that are either investigational or already available or noninvasive approaches such as surveys, education, and interviews.
Drug:DabigatranDabigatran 110 mg taken twice daily
Drug:Placebo (for Dabigatran)Dabigatran placebo taken twice daily
Drug:OmeprazoleOmeprazole 20 mg capsule taken once daily
Drug:Placebo (for Omeprazole)Omeprazole placebo taken once daily
Research studies and clinical trials typically have two or more research arms. An arm is a group of people who receive the same treatment in the study.
DabigatranDabigatran 110 mg capsule taken twice daily
OmeprazoleOmeprazole 20 mg capsule taken once daily
Placebo (dabigatran)Dabigatran placebo taken twice daily
Placebo (omeprazole)Omeprazole placebo taken once daily
Start Date: January 2013
Completed Date: March 1, 2018
Phase: Phase 3
Primary Outcome: Major vascular complication (for Dabigatran)
Secondary Outcome: Individual secondary outcomes for Dabigatran
Study sponsors, principal investigator, and references
Principal Investigator: P.J. Devereaux, MD, PhD
Lead Sponsor: Population Health Research Institute
Duceppe E, Yusuf S, Tandon V, Rodseth R, Biccard BM, Xavier D, Szczeklik W, Meyhoff CS, Franzosi MG, Vincent J, Srinathan SK, Parlow J, Magloire P, Neary J, Rao M, Chaudhry NK, Mayosi B, de Nadal M, Popova E, Villar JC, Botto F, Berwanger O, Guyatt G, Eikelboom JW, Sessler DI, Kearon C, Pettit S, Connolly SJ, Sharma M, Bangdiwala SI, Devereaux PJ. Design of a Randomized Placebo-Controlled Trial to Assess Dabigatran and Omeprazole in Patients with Myocardial Injury after Noncardiac Surgery (MANAGE). Can J Cardiol. 2018 Mar;34(3):295-302. doi: 10.1016/j.cjca.2018.01.020. Epub 2018 Feb 2.