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

Research output: Contribution to journalJournal articleResearchpeer-review

  • P J Devereaux
  • Emmanuelle Duceppe
  • Gordon Guyatt
  • Vikas Tandon
  • Reitze Rodseth
  • Bruce M Biccard
  • Denis Xavier
  • Wojciech Szczeklik
  • Meyhoff, Christian Sylvest
  • Jessica Vincent
  • Maria Grazia Franzosi
  • Sadeesh K Srinathan
  • Jason Erb
  • Patrick Magloire
  • John Neary
  • Mangala Rao
  • Prashant V Rahate
  • Navneet K Chaudhry
  • Bongani Mayosi
  • Miriam de Nadal
  • Pilar Paniagua Iglesias
  • Otavio Berwanger
  • Juan Carlos Villar
  • Fernando Botto
  • John W Eikelboom
  • Daniel I Sessler
  • Clive Kearon
  • Shirley Pettit
  • Mukul Sharma
  • Stuart J Connolly
  • Shrikant I Bangdiwala
  • Purnima Rao-Melacini
  • Andreas Hoeft
  • Salim Yusuf
  • MANAGE Investigators

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 110 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 [corrected].

FUNDING: Boehringer Ingelheim and Canadian Institutes of Health Research.

Original languageEnglish
Issue number10137
Pages (from-to)2325-2334
Publication statusPublished - 2018

    Research areas

  • Aged, Aged, 80 and over, Antithrombins/pharmacology, Dabigatran/administration & dosage, Female, Hemorrhage/complications, Humans, Male, Myocardial Infarction/drug therapy, Omeprazole/administration & dosage, Perioperative Period/mortality, Peripheral Arterial Disease/complications, Placebo Effect, Proton Pump Inhibitors/therapeutic use, Stroke/complications, Thrombosis/pathology, Treatment Outcome, Troponin/drug effects, Venous Thromboembolism/drug therapy

ID: 211819802