European Society of Cardiology
European Society of Cardiology
Perspective from Peter Libby, MD
Source/Disclosures
Source:

Anstensrud AK, et al. Late-Breaking Science in Acute Coronary Syndromes 1. Presented at: European Society of Cardiology Congress; Aug. 29-Sept. 1, 2020 (virtual meeting).

Disclosures: Anstensrud reports no relevant financial disclosures.
September 02, 2020
2 min read
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IL-6 receptor inhibitor improves myocardial salvage in STEMI: ASSAIL-MI

Perspective from Peter Libby, MD
Source/Disclosures
Source:

Anstensrud AK, et al. Late-Breaking Science in Acute Coronary Syndromes 1. Presented at: European Society of Cardiology Congress; Aug. 29-Sept. 1, 2020 (virtual meeting).

Disclosures: Anstensrud reports no relevant financial disclosures.
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Tocilizumab, an interleukin-6 receptor inhibitor, improved myocardial salvage in patients with first-time acute STEMI compared with placebo, according to the ASSAIL-MI trial presented at the European Society of Cardiology Congress.

“Our findings suggest that IL-6 receptor inhibition is an interesting therapeutic target on top of conventional medical treatment,” Anne Kristine Anstensrud, MD, cardiologist at Oslo University Hospital in Norway, told Healio. “In a subpopulation analysis, patients admitted to hospital within 3 to 6 hours after onset of symptoms were shown to have a benefit of the IL-6 receptor inhibition. Overall, the study medication was safe and well tolerated.”

Myocardial salvage index among patients with STEMI who received tocilizumab compared with placebo.

In this multicenter, randomized clinical trial, researchers analyzed data from 199 patients who presented with 6 hours of chest pain, had ST-segment elevation and were indicated for urgent coronary angiography with the intent to reperfuse a potentially occluded vessel. After hospital admission, patients were randomly assigned a single infusion of tocilizumab (Actemra, Genentech; mean age, 62 years; 79% men) or placebo (mean age, 60 years; 89% men). Both groups received their assigned treatments before undergoing PCI.

Anne Kristine Anstensrud

“It has been shown with interleukin-6 inhibition with tocilizumab reduces the inflammatory response after NSTEMI and diminishes the release of troponin T particularly in those undergoing PCI, suggesting that tocilizumab can have a protective effect on the ischemia reperfusion injury,” Anstensrud said during the presentation.

The primary endpoint was myocardial salvage index, which was measured by cardiac MRI between 3 and 7 days after randomization. Secondary endpoints included final infarct size after 6 months, area under the receiver operating characteristic curve (AUC) for troponin T during index hospitalization, AUC of C-reactive protein during index hospitalization, and safety and tolerability.

Follow-up was conducted through 6 months and include cardiac MRI, echocardiography and blood samples, in addition to safety measurements.

The myocardial salvage index in patients assigned tocilizumab was 69% compared with 64% in those assigned placebo (adjusted between-group difference, 5.6 percentage points; P = .042).

In a prespecified subgroup analysis, the treatment effect of tocilizumab was greater in patients with symptom onset of more than 3 hours compared with those with symptom onset of 3 hours or less (P for interaction = .034). There was also a trend toward the treatment effect being greater in men than women (P for interaction = .053).

The final infarct size in patients assigned tocilizumab was 12.6 g compared with 15 g in those assigned placebo, but the difference did not reach statistical significance (P = .08). The AUC for troponin T also did not reach statistical significance, although the level was higher in the placebo group compared with the tocilizumab group (2,357 ng/L/h vs. 1,614 ng/L/h; P = .13). The AUC for CRP was lower in the tocilizumab group compared with the placebo group (1.9 mg/L/h vs. 8.6 mg/L/h; P < .001).

“As expected, there was a significant difference in CRP [favoring] tocilizumab,” she said.

Other factors did not differ between both groups including N-terminal pro-B-type natriuretic peptide, left ventricular end-diastolic volume, serious adverse events and infections requiring hospitalization.

“The ASSAIL-MI trial was a phase 2 trial,” Anstensrud said in an interview. “Further research is needed both to evaluate the effect in a larger study population according to clinical endpoints, but also to select patients that might have the most beneficial effect of the anti-inflammatory treatment.”