Patients who survive STEMI often go on to develop infarct expansion and myocardial thinning which can lead to heart failure and, ultimately, death. In an attempt to limit this phenomenon, several agents have been proposed, amongst them erythropoietin. In addition to its effects on red blood cell production, erythropoietin also stimulates angiogenesis and apoptosis, and several animal models have suggested that it can have a cardioprotective role in myocardial ischaemia. Therefore the purpose of the REVEAL (Reduction of Infarct Expansion and Ventricular Remodelling With Erythropoietin After Large Myocardial Infarction) trial was to evaluate the safety and efficacy of a single intravenous bolus of erythropoietin alfa in patients with STEMI. Cardiac Magnetic Resonance (CMR) was used to determine infarct size at 2-6 days after study medication administration, and then again 12 weeks later.
Overall the study found no significant difference between infarct size in patients given IV epoetin alfa or placebo saline infusion at the time of the first CMR scan(n=136, 15.8% LV mass in for the epoetin group vs. 15.0% for the saline group; P=0.67). A similar result was seen when the patients returned for a second scan (P=0.89). Furthermore, in a prespecified analysis of patients aged 70 or older, a larger infarct size was seen in the first week in the epoetin alfa group (19.9% LV mass vs. 11.7% LV mass; P=0.03). Also, in a safety cohort of 125 patients treated with epoetin alfa, the composite outcome of death, MI, stroke, or stent thrombosis occurred in 5 people, but in none of the 97 patients who received placebo (P=.04).
Conclusions:
In this study of the use of erythropoietin in STEMI, no reduction in infarct size was found. Higher rates of adverse cardiovascular events and increases in infarct size in elderly patients were noted.
- Najjar SS, Rao SV, Melloni C et al. Intravenous Erythropoietin in Patients With ST-Segment Elevation Myocardial Infarction REVEAL: A Randomized Controlled Trial. JAMA 2001;305:1863-1872