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Published on: February 26, 2013
Anticoagulation with otamixaban and ischemic events in non-ST-segment elevation acute coronary syndromes: the TAO
Philippe Gabriel Steg1, Shamir R Mehta, Charles V Pollack
1Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France. gabriel.steg@bch.aphp.fr
Insights
Otamixaban did not improve outcomes for acute coronary syndrome patients but increased bleeding risk. Unfractionated heparin with eptifibatide remains a preferred treatment for non-ST-segment elevation acute coronary syndromes.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Optimal anticoagulation for non-ST-segment elevation acute coronary syndromes (NSTE-ACS) with an invasive strategy is debated.
- Direct factor Xa inhibitors are a novel class of anticoagulants.
Purpose of the Study:
- To compare the efficacy and safety of otamixaban versus unfractionated heparin plus eptifibatide in NSTE-ACS patients.
- To evaluate otamixaban's role in planned early invasive strategies.
Main Methods:
- A randomized, double-blind, active-controlled superiority trial involving 13,229 NSTE-ACS patients.
- Patients received either otamixaban or unfractionated heparin plus eptifibatide during percutaneous coronary intervention.
- Primary efficacy outcome: composite of death or new myocardial infarction by day 7.
Main Results:
- Otamixaban (5.5%) did not significantly differ from unfractionated heparin plus eptifibatide (5.7%) for the primary efficacy outcome (adjusted RR, 0.99; P=.93).
- Bleeding events were significantly higher with otamixaban (3.1%) compared to unfractionated heparin plus eptifibatide (1.5%; RR, 2.13; P<.001).
- No differences observed in secondary endpoints, including procedural thrombotic complications.
Conclusions:
- Otamixaban is not superior to unfractionated heparin plus eptifibatide in reducing ischemic events in NSTE-ACS patients.
- Otamixaban significantly increases bleeding risk, making it unsuitable for this patient population.
- Current findings do not support otamixaban use in NSTE-ACS patients undergoing early percutaneous coronary intervention.
Importance:
The optimal anticoagulant for patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) managed with an invasive strategy remains controversial.
Objective:
To compare the clinical efficacy and safety of otamixaban, a novel intravenous direct factor Xa inhibitor, with that of unfractionated heparin plus downstream eptifibatide in patients with NSTE-ACS undergoing a planned early invasive strategy.
Design, Setting, And Participants:
Randomized, double-blind, active-controlled superiority trial that enrolled 13,229 patients with NSTE-ACS and a planned early invasive strategy, at 568 active sites in 55 countries and conducted between April 2010 and February 2013. A planned interim analysis was conducted for otamixaban dose selection.
Interventions:
Eligible participants were randomized to otamixaban (bolus and infusion, at 1 of 2 doses) or unfractionated heparin plus, at the time of percutaneous coronary intervention, eptifibatide. The otamixaban dose selected at interim analysis was an intravenous bolus of 0.080 mg/kg followed by an infusion of 0.140 mg/kg per hour.
Main Outcomes And Measures:
The primary efficacy outcome was the composite of all-cause death or new myocardial infarction through day 7.
Results:
Rates of the primary efficacy outcome were 5.5% (279 of 5105 patients) randomized to receive otamixaban and 5.7% (310 of 5466 patients) randomized to receive unfractionated heparin plus eptifibatide (adjusted relative risk, 0.99 [95% CI, 0.85-1.16]; P = .93). There were no differences for the secondary end points, including procedural thrombotic complications. The primary safety outcome of Thrombosis in Myocardial Infarction major or minor bleeding through day 7 was increased by otamixaban (3.1% vs 1.5%; relative risk, 2.13 [95% CI, 1.63-2.78]; P < .001). Results were consistent across prespecified subgroups.
Conclusions And Relevance:
Otamixaban did not reduce the rate of ischemic events relative to unfractionated heparin plus eptifibatide but did increase bleeding. These findings do not support the use of otamixaban for patients with NSTE-ACS undergoing planned early percutaneous coronary intervention.
Trial Registration:
clinicaltrials.gov Identifier: NCT01076764.
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