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Kumar K, Golwala H. Antiplatelet Agents in Acute ST Elevation Myocardial Infarction. Am J Med 2022; 135:697-708. [PMID: 35202571 DOI: 10.1016/j.amjmed.2022.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 11/28/2022]
Abstract
Platelet aggregation and thrombus formation represent the basic mechanism for clinical, electrocardiographic, and biomarker changes consistent with acute coronary syndrome. Various oral and intravenous formulations of platelet function inhibitors have been developed to help decrease platelet aggregation due to acute atherosclerotic plaque rupture. In this article, we review the various mechanisms, pharmacokinetics/pharmacodynamics, and the key clinical trials related to the platelet inhibitors that form the basis for current recommendations of their use in the ST elevation myocardial infarction guidelines by the American College of Cardiology/American Heart Association.
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Affiliation(s)
- Kris Kumar
- Oregon Health and Science University, Portland, Ore
| | - Harsh Golwala
- Oregon Health and Science University, Portland, Ore.
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2
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Kaddoura R, Mohamed Ibrahim MI, Al-Badriyeh D, Omar A, Al-Kindi F, Arabi AR. Intracoronary pharmacological therapy versus aspiration thrombectomy in STEMI (IPAT-STEMI): A systematic review and meta-analysis of randomized trials. PLoS One 2022; 17:e0263270. [PMID: 35512007 PMCID: PMC9071172 DOI: 10.1371/journal.pone.0263270] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Thrombus load in STEMI patients remains a challenge in practice. It aggravates coronary obstruction leading to impaired myocardial perfusion, worsened cardiac function, and adverse clinical outcomes. Various strategies have been advocated to reduce thrombus burden. OBJECTIVES This meta-analysis aimed to evaluate the effectiveness of intracoronary-administered thrombolytics or glycoprotein IIb/IIIa inhibitors (GPI) in comparison with aspiration thrombectomy (AT) as an adjunct to percutaneous coronary intervention (PCI) among patients presenting with ST-segment elevation myocardial infarction (STEMI). METHODS A comprehensive literature search for randomized trials that compared intracoronary-administered thrombolytics or GPI with AT in STEMI patients who underwent PCI, was conducted using various databases (e.g., MEDLINE, EMBASE, CENTRALE). Primary outcome was procedural measures (e.g., TIMI flow grade 3, TIMI myocardial perfusion grade (TMPG) 3, Myocardial blush grade (MBG) 2/3, ST-segment resolution (STR)). RESULTS Twelve randomized trials enrolled 1,466 patients: 696 were randomized to intracoronary-administered pharmacological interventions and 553 to AT. Patients randomized to PCI alone were excluded. Thrombolytics significantly improved TIMI flow grade 3 (odds ratio = 3.71, 95% CI: 1.85-7.45), complete STR (odds ratio = 3.64, 95% CI: 1.60-8.26), and TMPG 3 (odds ratio = 5.31, 95% CI: 2.48-11.36). Thrombolytics significantly reduced major adverse cardiovascular events (MACE) (odds ratio = 0.29, 95% CI: 0.13-0.65) without increasing bleeding risk. Trial sequential analysis assessment confirmed the superiority of thrombolytics for the primary outcome. Intracoronary GPI, either alone or combined with AT, did not improve procedural or clinical outcomes. CONCLUSIONS Compared with AT, intracoronary-administered thrombolytics significantly improved myocardial perfusion and MACE in STEMI patients.
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Affiliation(s)
- Rasha Kaddoura
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Amr Omar
- Department of Cardiothoracic Surgery/Cardiac Anesthesia, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Fahad Al-Kindi
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abdul Rahman Arabi
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Ajlani B, Gibault-Genty G, Cherif G, Blicq E, Azzaz S, Schiano P, Brami M, Sarfati L, Charbonnel C, Convers-Domart R, Livarek B, Georges JL. [Intracoronary administration of antithrombotic agents via a perfusion balloon catheter in patients with ST-segment elevation myocardial infarction presenting with massive intraluminal thrombus and failed aspiration]. Ann Cardiol Angeiol (Paris) 2016; 65:299-305. [PMID: 27693166 DOI: 10.1016/j.ancard.2016.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 09/02/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Massive intracoronary thrombus is associated with adverse procedural results including failed aspiration and unfavourable reperfusion. We aim to evaluate the effect of the intracoronary administration of antithrombotic agents via a perfusion catheter in patients with ST-segment elevation myocardial infarction (STEMI) presenting with a large thrombus burden and failed aspiration. METHODS We retrospectively analyzed the thrombus burden, the TIMI grade flow, and the myocardial Blush in 25 consecutive STEMI patients with a large thrombus burden and failed manual aspiration, who received intracoronary infusion of glycoprotein IIb/IIIa inhibitors (N=17) or bivalirudine (N=8) via a 6F-infusion catheter (ClearWay™ RX) RESULTS: Mean age was 67±14 years, 16 patients (64 %) presented with anterior STEMI, and 7 (28 %) with cardiogenic shock. Immediately after intracoronary infusion, the TIMI flow grade improved of 2 grades in 7 patients (28 %), and 1 grade in 14 (56 %), a complete resolution of the thrombus was observed in 9 patients, and a >50 % resolution in 12. Blush was improved of 3 grades in 15 patients (60 %), of 2 grades in 7 (28 %), and Blush grade 0 remained in 3. At the end of procedure, we observed normal TIMI 3flow in most patients (92 %), a complete resolution of thrombus in 80 %, and a Blush grade 3 in 68 %. CONCLUSIONS In STEMI patients presenting with a large thrombus burden and failed aspiration, intracoronary administration of glycoprotein IIb/IIIa inhibitors or bivalirudin via the perfusion catheter ClearWay™ RX significantly reduced the thrombus burden and improved the TIMI flow and the Blush grade, without bleeding.
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Affiliation(s)
- B Ajlani
- Service de cardiologie, unité de soins intensif cardiologiques et cardiologie interventionnelle, centre hospitalier de Versailles, hôpital André-Mignot, 177, rue de Versailles, 78150 Le Chesnay, France
| | - G Gibault-Genty
- Service de cardiologie, unité de soins intensif cardiologiques et cardiologie interventionnelle, centre hospitalier de Versailles, hôpital André-Mignot, 177, rue de Versailles, 78150 Le Chesnay, France
| | - G Cherif
- Service de cardiologie, unité de soins intensif cardiologiques et cardiologie interventionnelle, centre hospitalier de Versailles, hôpital André-Mignot, 177, rue de Versailles, 78150 Le Chesnay, France
| | - E Blicq
- Service de cardiologie, unité de soins intensif cardiologiques et cardiologie interventionnelle, centre hospitalier de Versailles, hôpital André-Mignot, 177, rue de Versailles, 78150 Le Chesnay, France
| | - S Azzaz
- Service de cardiologie, unité de soins intensif cardiologiques et cardiologie interventionnelle, centre hospitalier de Versailles, hôpital André-Mignot, 177, rue de Versailles, 78150 Le Chesnay, France
| | - P Schiano
- Service de cardiologie, unité de soins intensif cardiologiques et cardiologie interventionnelle, centre hospitalier de Versailles, hôpital André-Mignot, 177, rue de Versailles, 78150 Le Chesnay, France
| | - M Brami
- Service de cardiologie, unité de soins intensif cardiologiques et cardiologie interventionnelle, centre hospitalier de Versailles, hôpital André-Mignot, 177, rue de Versailles, 78150 Le Chesnay, France; Service de cardiologie, centre médico chirurgical de l'Europe, 78560 Le Port Marly, France
| | - L Sarfati
- Service de cardiologie, unité de soins intensif cardiologiques et cardiologie interventionnelle, centre hospitalier de Versailles, hôpital André-Mignot, 177, rue de Versailles, 78150 Le Chesnay, France; Service de cardiologie, centre médico chirurgical de l'Europe, 78560 Le Port Marly, France
| | - C Charbonnel
- Service de cardiologie, unité de soins intensif cardiologiques et cardiologie interventionnelle, centre hospitalier de Versailles, hôpital André-Mignot, 177, rue de Versailles, 78150 Le Chesnay, France
| | - R Convers-Domart
- Service de cardiologie, unité de soins intensif cardiologiques et cardiologie interventionnelle, centre hospitalier de Versailles, hôpital André-Mignot, 177, rue de Versailles, 78150 Le Chesnay, France
| | - B Livarek
- Service de cardiologie, unité de soins intensif cardiologiques et cardiologie interventionnelle, centre hospitalier de Versailles, hôpital André-Mignot, 177, rue de Versailles, 78150 Le Chesnay, France
| | - J-L Georges
- Service de cardiologie, unité de soins intensif cardiologiques et cardiologie interventionnelle, centre hospitalier de Versailles, hôpital André-Mignot, 177, rue de Versailles, 78150 Le Chesnay, France.
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Sharma S, Makkar R, Lardizabal J. Intracoronary Administration of Abciximab During Percutaneous Coronary Interventions: Should This Be the Routine and Preferred Approach? J Cardiovasc Pharmacol Ther 2016; 11:136-41. [PMID: 16891291 DOI: 10.1177/1074248406288761] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The authors have had experience with administering abciximab as an intracoronary bolus in 96 high-risk patients undergoing percutaneous coronary interventions, specifically in situations in which there was anticipation of a high embolic load from thrombus/plaque burden at the site of the culprit lesion, saphenous vein graft culprit lesion, threatened abrupt closure, developing slow-flow, or no-reflow phenomena with distal embolization. Our uncontrolled data basically substantiate the safety of intracoronary administration of abciximab. The data summarizing the potential superiority of this method of administration of the drug and the likely mechanisms of this effect are summarized. These incite a need for reevaluation of the method of administration of the drug, especially in high-risk percutaneous coronary interventions cases
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Affiliation(s)
- Sanjiv Sharma
- Division of Cardiology, Bakersfield Heart Hospital, 2110 Truxtun Avenue, Bakersfield, CA 93301, USA.
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Esfandi A, Fotouhi M, Allami A, Ebrahimi M. Comparison between the Outcomes of Intracoronary and Intravenous Administration of Eptifibatide during Primary Percutaneous Coronary Intervention in Patients with Acute ST-Elevation Myocardial Infarction. J Atheroscler Thromb 2015; 23:465-76. [PMID: 26632161 DOI: 10.5551/jat.30965] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIM To compare the outcomes of intracoronary (IC) and intravenous (IV) administration of eptifibatide during primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI). METHODS In this prospective double-blind randomized clinical trial, 76 patients with STEMI selected for PPCI were randomly assigned in two groups to receive either IC or IV bolus of eptifibatide. The primary end point was coronary perfusion assessment by thrombolysis in myocardial infarction (TIMI) flow grade (TFG), TIMI perfusion grade (TPG), and corrected TIMI frame count (cTFC). Secondary end points were left ventricular ejection fraction (LVEF) restoration, ST-segment elevation resolution, and in-hospital major cardiovascular adverse events (MACEs) (including recurrent MI, need for target vessel revascularization (TVR), stroke, and death resulting from any cause) until discharge. RESULTS Assessment revealed significantly better TFG (95% CI: 1.01-10.26, OR=3.224, P=0.042), more TFG 3 (65.79% vs. 86.11% in IV and IC groups, respectively), better TPG (P=0.024), more achieved TPG 3 and TPG 2+3 (TPG 3: 44.74% vs. 72.22% and TPG 2+3: 78.95% vs. 94.44% in the IV and IC groups, respectively) with better cTFC in the IC group (37.33±15.84 vs. 32.53± 20.71 in the IV and IC groups, respectively; P=0.034). LVEF was better restored in the IC group (6.21±8.61% vs. 14.72±5.34% in the IV and IC groups, respectively; P<0.001) and the ST-segment elevation resolution was better achieved in the IC administration (95% CI: -22.55 to -6.23, P=0.001). There were no recurrent MI, stroke, or need for TVR among patients during the in-hospital stay. CONCLUSIONS IC administration of eptifibatide during PPCI in patients with STEMI in comparison with IV administration of eptifibatide is associated with significantly better coronary reperfusion and improved clinical outcomes (IRCT2012090510751N1).
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Affiliation(s)
- Amir Esfandi
- Department of Cardiology, Bu-Ali Sina Hospital, Qazvin University of Medical Sciences
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Adenosine as an Adjunct Therapy in ST Elevation Myocardial Infarction Patients: Myth or Truth? Cardiovasc Drugs Ther 2015; 29:481-93. [DOI: 10.1007/s10557-015-6606-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Secco GG, Sansa M, Rognoni A, Parisi R, Fattori R, Rossi L, Lazzero M, Rolla R, Bellomo G, Bongo AS, Agostoni P, Di Mario C, Lupi A. Similar anti-inflammatory effects of intracoronary and intravenous Abciximab during primary percutaneous coronary intervention. J Cardiovasc Med (Hagerstown) 2015; 16:189-96. [DOI: 10.2459/jcm.0000000000000119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Thind GS, Parida R, Gupta N. Pharmacotherapy in the cardiac catheterization laboratory: evolution and recent developments. Ther Clin Risk Manag 2014; 10:885-900. [PMID: 25364258 PMCID: PMC4211856 DOI: 10.2147/tcrm.s71927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Many recent innovations have been made in developing new antiplatelet and anticoagulant drugs in the last few years, with a total of nine new antithrombotic drugs approved by the Food and Drug Administration after the year 2000. This has revolutionized the medical therapy given to manage acute coronary syndrome and support cardiac catheterization. The concept of dual antiplatelet therapy has been emphasized, and clopidogrel has emerged as the most-popular second antiplatelet drug after aspirin. Newer P2Y12 inhibitors like prasugrel and ticagrelor have been extensively studied and compared to clopidogrel. The role of glycoprotein (Gp) IIb/IIIa inhibitors is being redefined. Other alternatives to unfractionated heparin have become available, of which enoxaparin and bivalirudin have been studied the most. Apart from these, many more drugs with novel therapeutic targets are being studied and are currently under development. In this review, current evidence on these drugs is presented and analyzed in a way that would facilitate decision making for the clinician. For this analysis, various high-impact clinical trials, pharmacological studies, meta-analyses, and reviews were accessed through the MEDLINE database. Adopting a unique interdisciplinary approach, an attempt has been made to integrate pharmacological and clinical evidence to better understand and appreciate the pros and cons of each of these classes of drugs.
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Affiliation(s)
| | - Raunak Parida
- SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India
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Nazir SA, Khan JN, Mahmoud IZ, Greenwood JP, Blackman DJ, Kunadian V, Been M, Abrams KR, Wilcox R, Adgey AAJ, McCann GP, Gershlick AH. The REFLO-STEMI trial comparing intracoronary adenosine, sodium nitroprusside and standard therapy for the attenuation of infarct size and microvascular obstruction during primary percutaneous coronary intervention: study protocol for a randomised controlled trial. Trials 2014; 15:371. [PMID: 25252600 PMCID: PMC4189551 DOI: 10.1186/1745-6215-15-371] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 09/10/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Microvascular obstruction (MVO) secondary to ischaemic-reperfusion injury is an important but underappreciated determinant of short- and longer-term outcome following percutaneous coronary intervention (PCI) treatment of ST-elevation myocardial infarction (STEMI). Several small studies have demonstrated a reduction in the degree of MVO utilising a variety of vasoactive agents, with adenosine and sodium nitroprusside (SNP) being most evaluated. However, the evidence base remains weak as the trials have had variable endpoints, differing drug doses and delivery. As such, the results regarding benefit are conflicting. METHODS The REperfusion Facilitated by LOcal adjunctive therapy in STEMI (REFLO-STEMI) trial is a multicentre, prospective, randomised, controlled, open label, study with blinded endpoint analysis: Patients presenting within 6 h of onset of STEMI and undergoing planned primary PCI (P-PCI) with TIMI 0/1 flow in the infarct-related artery (IRA) and no significant bystander coronary artery disease on angiography, are randomised into one of three groups: PCI with adjunctive pharmacotherapy (intracoronary adenosine or SNP) or control (standard PCI). All receive Bivalirudin anticoagulation and thrombus aspiration. The primary outcome is infarct size (IS) (determined as a percentage of total left ventricular mass) measured by cardiac magnetic resonance imaging (CMRI) undertaken at 48 to 72 h post P-PCI. Secondary outcome measures include MVO (hypoenhancement within infarct core) on CMRI, angiographic markers of microvascular perfusion and MACE during 1-month follow-up. The study aims to recruit 240 patients (powered at 80% to detect a 5% absolute reduction in IS). DISCUSSION The REFLO-STEMI study has been designed to address the weaknesses of previous trials, which have collectively failed to demonstrate whether adjunctive pharmacotherapy with adenosine and/or SNP can reduce measures of myocardial injury (infarct size and MVO) and improve clinical outcome, despite good basic evidence that they have the potential to attenuate this process. The REFLO-STEMI study will be the most scientifically robust trial to date evaluating whether adjunctive therapy (intracoronary adenosine or SNP following thrombus aspiration) reduces CMRI measured IS and MVO in patients undergoing P-PCI within 6 h of onset of STEMI. TRIAL REGISTRATION Trial registered 20th November 2012: ClinicalTrials.gov Identifier NCT01747174.
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Affiliation(s)
- Sheraz A Nazir
- />Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, LE3 9QP Leicester, UK
| | - Jamal N Khan
- />Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, LE3 9QP Leicester, UK
| | - Islam Z Mahmoud
- />Department of Cardiovascular Imaging, Division of Imaging Sciences & Biomedical Engineering, Rayne Institute, BHF Excellence Centre, St Thomas’ Hospital, King’s College London, London, UK
| | - John P Greenwood
- />Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, UK
| | - Daniel J Blackman
- />Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, UK
| | - Vijay Kunadian
- />Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Martin Been
- />Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Keith R Abrams
- />Centre for Biostatistics & Genetic Epidemiology, Department of Health Sciences, School of Medicine, University of Leicester, Leicester, UK
| | - Robert Wilcox
- />Faculty of Medicine & Health Sciences, Queen’s Medical Centre, Nottingham, UK
| | - AA Jennifer Adgey
- />Heart Centre, Royal Victoria Hospital, Belfast, Northern Ireland, UK
| | - Gerry P McCann
- />Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, LE3 9QP Leicester, UK
| | - Anthony H Gershlick
- />Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, LE3 9QP Leicester, UK
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Shakoor MT. Complications of intracoronary abciximab bolus-only versus standard protocol during percutaneous coronary intervention in acute coronary syndrome. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VESSELS 2014; 3:64-67. [PMID: 29450173 PMCID: PMC5801446 DOI: 10.1016/j.ijchv.2014.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 03/10/2014] [Indexed: 06/08/2023]
Abstract
BACKGROUND Abciximab reduces major adverse cardiac events in patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention (pPCI). Standard protocol is intravenous abciximab bolus during PCI plus abciximab infusion for 12-18 h post pPCI. Intracoronary (IC) abciximab bolus administration results in high local drug concentrations and hence it should have higher antiplatelet effect. In this study, we assess the short-term efficacy and safety of IC compared to IV bolus of abciximab in ACS patients during pPCI. METHODS We compared the clinical outcomes between the IC (n = 56) and standard protocol (n = 170) group of patients. Primary endpoints included bleeding/vascular/ischemic complications and MACE. RESULTS The two groups were similar with respect to baseline characteristics. IC abciximab bolus only reduced bleeding complications, with no moderate bleed versus 7.2% in standard protocol group (p value 0.04). Ischemic/vascular complications had statistically insignificant difference between the two groups. CONCLUSION We found no significant difference between IC abciximab bolus only and standard abciximab therapy in terms of ischemic/vascular complications and MACE. But there was higher risk of moderate bleed in standard therapy group. The IC bolus route of abciximab may be superior to the intravenous route. Prospective randomized trials are warranted to validate these findings.
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Affiliation(s)
- Muhammad Tariq Shakoor
- Corresponding author at: Baystate Medical Center, MA, United States. Tel.: + 1 413 231 2431 (Cell)Corresponding author at: Baystate Medical CenterTel.: + 1 413 231 2431 (Cell)MAUnited States
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De Rosa S, Caiazzo G, Torella D, Indolfi C. Intracoronary abciximab reduces death and major adverse cardiovascular events in acute coronary syndromes: A meta-analysis of clinical trials. Int J Cardiol 2013; 168:1298-305. [DOI: 10.1016/j.ijcard.2012.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 10/08/2012] [Accepted: 12/01/2012] [Indexed: 11/28/2022]
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12
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Intracoronary abciximab in STEMI using local drug delivery catheter - single center experience. Indian Heart J 2013; 65:256-9. [PMID: 23809377 DOI: 10.1016/j.ihj.2013.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 12/31/2012] [Accepted: 04/03/2013] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Despite restoration of epicardial flow during primary PCI in STEMI, microvascular obstruction may persist as a result of both atheromatous and thrombotic embolization and vasospasm. Compared with the systemic administration of IV pharmaco-therapies, highly localized administration of intracoronary pharmacotherapy may be associated with a several-hundred-fold increase in the local concentration of an agent in the epicardial artery and microcirculation. Despite restoration of epicardial flow during primary PCI in STEMI, microvascular obstruction may persist as a result of both atheromatous and thrombotic embolization and vasospasm. We are presenting our experience with use of intracoronary abciximab using local drug delivery catheter in STEMI patients. METHODS We retrospectively evaluated 15 patients presented to us with STEMI undergoing primary PCI between March 2011 and September 2012 who had super selective intracoronary abciximab using local drug delivery catheter. With standard antiplatelet therapy, both Pre and Post TIMI flow, TMP grading were assessed. RESULTS Mean age was 55 years. The TIMI flow increased by 3 grades in thirteen patients, TMP grading increased by 2 grades in five patients and by 3 grades in nine patients. Thus TIMI flow and TMP grading improved after super selective intracoronary abciximab. CONCLUSION Super selective intracoronary abciximab using local drug delivery catheter during primary PCI in STEMI patients significantly improves TMP grading without increased risk of bleeding. This benefit is achieved even in patients without thrombus aspiration. We need to assess the long-term outcomes in the form of reduction in infarct size using this strategy in large group of patients.
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Wang JN, Diao S, Tang YJ, Hou AJ, Yuan HB, Zheng Y, Zhou YH. Intracoronary versus intravenous administration of abciximab in patients with acute coronary syndrome: a meta-analysis. PLoS One 2013; 8:e58077. [PMID: 23469144 PMCID: PMC3585408 DOI: 10.1371/journal.pone.0058077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 01/30/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Abciximab is a widely used adjunctive therapy for acute coronary syndrome (ACS). However, the effect of intracoronary (i.c.) administration of abciximab on cardiovascular events remains unclear when compared with intravenous (i.v.) therapy. METHODOLOGY AND PRINCIPAL FINDINGS We systematically searched the Medline, Embase, and Cochrane Central Register of Controlled Trials databases and reference lists of articles and proceedings of major meetings for obtaining relevant literature. All eligible trials included ACS patients who received either i.c. administration of abciximab or i.v. therapy. The primary outcome was major cardiovascular events, and secondary outcomes included total mortality, reinfarction, and any possible adverse events. Of 660 identified studies, we included 9 trials reporting data on 3916 ACS patients. Overall, i.c. administration of abciximab resulted in 45% reduction in relative risk for major cardiovascular events (RR; 95% confidence interval [CI], 24-60%), 41% reduction in RR for reinfarction (95% CI, 7-63%), and 44% reduction in RR for congestive heart failure relative to i.v. therapy (95% CI, 8-66%); however, compared to i.v. therapy, i.c. administration of abciximab had no effect on total mortality (RR, 0.69; 95% CI, 0.45-1.07). No other significant differences were identified between the effect of i.c. abciximab administration and i.v. therapy. CONCLUSIONS/SIGNIFICANCE I.c. administration of abciximab can reduce the risk of major cardiovascular events, reinfarction, and congestive heart failure when compared with i.v. therapy.
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Affiliation(s)
- Jie-Ning Wang
- Director of the Hospital, Shanghai Seventh People’s Hospital, Shanghai, China
| | - Shu Diao
- Vice Director of the Hospital, Shanghai Seventh People’s Hospital, Shanghai, China
| | - Yuan-Jun Tang
- Department of Pharmaceutical Analysis, School of Pharmacy, Second Military Medical University, Shanghai, China
| | - An-Ji Hou
- Department of Oncology, Shanghai Seventh People’s Hospital, Shanghai, China
| | - Hai-Bo Yuan
- Department of Science, Shanghai Seventh People’s Hospital, Shanghai, China
| | - Yan Zheng
- Department of Science, Shanghai Seventh People’s Hospital, Shanghai, China
| | - Yu-Hao Zhou
- Department of Rehabilitation Institute, Shanghai Seventh People’s Hospital, Shanghai, China
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012; 61:485-510. [PMID: 23256913 DOI: 10.1016/j.jacc.2012.11.018] [Citation(s) in RCA: 462] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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15
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012; 127:e362-425. [PMID: 23247304 DOI: 10.1161/cir.0b013e3182742cf6] [Citation(s) in RCA: 1071] [Impact Index Per Article: 89.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012; 127:529-55. [PMID: 23247304 DOI: 10.1161/cir.0b013e3182742c84] [Citation(s) in RCA: 1817] [Impact Index Per Article: 151.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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17
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012; 61:e78-e140. [PMID: 23256914 DOI: 10.1016/j.jacc.2012.11.019] [Citation(s) in RCA: 2191] [Impact Index Per Article: 182.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2012; 79:453-95. [PMID: 22328235 DOI: 10.1002/ccd.23438] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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19
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Fu G, Jia L, Zhao X, Wang Y, Chen X, Yang Y, Lu N, Zhao W, Hui R, Zheng Y. A comparison of intracoronary with intravenous glycoprotein IIb/IIIa inhibitors during percutaneous coronary intervention in patients with acute coronary syndrome: a meta-analysis of randomized controlled trials. J Interv Cardiol 2012; 25:223-34. [PMID: 22413751 DOI: 10.1111/j.1540-8183.2011.00711.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND It is still debatable whether intracoronary (IC) administration of glycoprotein IIb/IIIa inhibitors (GPIs) is superior to intravenous (IV) administration for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). METHODS We performed a meta-analysis of randomized controlled clinical trials. A literature search was conducted for relevant trials. Primary end-points were short-term (1-3 months) and mid-/long-term (6/12 months) major adverse cardiovascular events (MACEs) (mortality, reinfarction, target vessel revascularization [TVR]). Secondary end-points were thrombolysis in myocardial infarction (TIMI) grade flow, TIMI myocardial perfusion grade (TMPG) flow, left ventricular ejection fraction (LVEF) within 2 weeks, and bleeding complication. RESULTS Twelve studies were included in the meta-analysis. IC administration of GPIs did not decrease short-term mortality (OR: 0.71, 95% CI: 0.41-1.23, P = 0.22) and reinfarction rate (OR: 0.76, 95% CI: 0.45-1.29, P = 0.31) compared with IV administration. There was a trend toward reduction of short-term TVR rate in IC group compared with IV group but not reaching statistical significance (OR: 0.57, 95% CI: 0.31-1.04, P = 0.07). IC administration of GPIs significantly increased TIMI grade 3 flow (OR: 1.48, 95% CI: 1.06-2.06, P = 0.02) and TMPG grade 2-3 flow (OR: 2.63, 95% CI: 1.53-4.51, P = 0.0004) compared with IV administration. No significant difference was observed in long-term MACEs rate, LVEF, and bleeding complication between the 2 groups. CONCLUSION IC administration of GPIs in patients with ACS undergoing PCI can significantly increase target coronary flow and myocardial reperfusion without increasing the risk of bleeding complication, but cannot improve clinical outcome compared with IV administration.
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Affiliation(s)
- Gang Fu
- Department of Cardiovascular Diseases, Bethune First Hospital of Jilin University, Changchun, China
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Shimada YJ, Nakra NC, Fox JT, Kanei Y. Meta-analysis of prospective randomized controlled trials comparing intracoronary versus intravenous abciximab in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Am J Cardiol 2012; 109:624-8. [PMID: 22152971 DOI: 10.1016/j.amjcard.2011.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 10/18/2011] [Accepted: 10/18/2011] [Indexed: 12/19/2022]
Abstract
Abciximab is a glycoprotein IIb/IIIa receptor inhibitor that has been shown to improve outcomes in patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention (pPCI). An earlier study reported better efficacy with intracoronary (IC) compared to intravenous (IV) administration, but this finding has not been duplicated in other studies, thus leaving a great deal of uncertainty as to the most efficacious route of administration. To investigate if IC abciximab compared to IV administration decreases mortality and major adverse cardiac events in patients with ST-segment elevation myocardial infarction who undergo pPCI, a meta-analysis was performed consisting only of prospective randomized controlled trials. Subgroup analysis was performed to investigate the source of difference in efficacy between the 2 strategies. A meta-analysis of 4 trials including 1,148 subjects revealed that IC abciximab significantly reduced mortality compared to IV administration (1.5% vs 3.6%, odds ratio 0.44, 95% confidence interval 0.20 to 0.95, p = 0.04). Major adverse cardiac events were also reduced in a subgroup in which <30% of patients received aspiration thrombectomy (6.1% vs 16.2%, odds ratio 0.33, 95% confidence interval 0.18 to 0.61, p = 0.0004). In conclusion, the totality of the data available from relatively small but high-quality studies shows a significant mortality reduction associated using IC abciximab for pPCI compared to IV abciximab. IC abciximab in the setting of pPCI for ST-segment elevation myocardial infarction may be beneficial for patients with higher risk profiles.
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary. J Am Coll Cardiol 2011. [DOI: 10.1016/j.jacc.2011.08.006] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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22
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Iversen AZ, Galatius S, Abildgaard U, Galloe A, Hansen PR, Pedersen S, Engstroem T, Jensen JS. Intracoronary Compared to Intravenous Abciximab in Patients with ST Segment Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention Reduces Mortality, Target Vessel Revascularization and Reinfarction after 1 Year. Cardiology 2011; 120:43-9. [DOI: 10.1159/000333117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 08/23/2011] [Indexed: 11/19/2022]
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23
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124:2574-609. [PMID: 22064598 DOI: 10.1161/cir.0b013e31823a5596] [Citation(s) in RCA: 381] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011; 58:e44-122. [PMID: 22070834 DOI: 10.1016/j.jacc.2011.08.007] [Citation(s) in RCA: 1724] [Impact Index Per Article: 132.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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25
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124:e574-651. [PMID: 22064601 DOI: 10.1161/cir.0b013e31823ba622] [Citation(s) in RCA: 901] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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26
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Jacobs AK, Anderson JL, Albert N, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. Catheter Cardiovasc Interv 2011; 82:E266-355. [DOI: 10.1002/ccd.23390] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kubica A, Kozinski M, Navarese EP, Grzesk G, Goch A, Kubica J. Intracoronary versus intravenous abciximab administration in STEMI patients: overview of current status and open questions. Curr Med Res Opin 2011; 27:2133-44. [PMID: 21942506 DOI: 10.1185/03007995.2011.621417] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To perform a systematic review to provide rationale for intracoronary (IC) abciximab administration in patients with ST-segment elevation myocardial infarction (STEMI), to summarize recent studies comparing IC vs. intravenous (IV) abciximab administration in this setting and to define questions that need to be answered in future trials determining the optimal abciximab regimen. METHODS A search covering the period from January 1993 to June 2011 was conducted by two independent investigators using MEDLINE, CENTRAL and Google Scholar databases. Proceedings from the scientific sessions of ACC, AHA, ESC, TCT and EuroPCR were also considered. RESULTS IC administration allows one to obtain a much higher concentration of abciximab than IV injection at the culprit lesion. Therefore it is hypothesized that IC abciximab administration provides more efficient GP IIb/IIIa receptor inhibition and more pronounced additional dose-dependent antiplatelet, antithrombotic, and anti-inflammatory effects when compared to the IV route. Numerous observational and randomized studies comparing IC vs. IV abciximab in STEMI patients indicated improvement in different surrogate end points (infarct size, obstruction of coronary microcirculation, ST segment resolution, inflammatory mediators and markers of platelet activation) related to IC administration. The evidence supporting clinical benefits associated with IC injection of abciximab comes from one randomized and several non-randomized trials as most of the studies were underpowered to assess clinical outcomes. No difference in bleeding complications was observed between IC and IV regimens. Issues that need to be addressed in future studies include: the use of IC abciximab in combination with thrombectomy, the role of selective delivery systems, and the necessity of a prolonged IV infusion of abciximab after IC bolus administration. CONCLUSIONS An accumulating body of evidence suggests the superiority of IC over IV abciximab administration in STEMI patients. However, further trials are warranted to establish the optimal strategy of abciximab treatment in this setting.
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Affiliation(s)
- Aldona Kubica
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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Friedland S, Eisenberg MJ, Shimony A. Meta-analysis of randomized controlled trials of intracoronary versus intravenous administration of glycoprotein IIb/IIIa inhibitors during percutaneous coronary intervention for acute coronary syndrome. Am J Cardiol 2011; 108:1244-51. [PMID: 22000626 DOI: 10.1016/j.amjcard.2011.06.039] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 06/27/2011] [Accepted: 06/27/2011] [Indexed: 01/11/2023]
Abstract
It is unclear whether intracoronary (IC) bolus administration of glycoprotein IIb/IIIa inhibitors (GPIs) during percutaneous coronary intervention (PCI) in patients with acute coronary syndromes is superior to intravenous (IV) administration. We conducted a meta-analysis of randomized controlled trials (RCTs) to compare the effects of IC and IV administrations of GPIs in patients with acute coronary syndromes. We systematically searched the Cochrane Library, EMBASE, and MEDLINE databases for RCTs comparing IC to IV administration of GPIs (abciximab, eptifibatide, tirofiban) during PCI. Data were pooled and stratified into short (1 month to 3 months) and mid-/long-term (≥6 months) follow-up durations. Ten RCTs involving 1,590 patients met our inclusion criteria. Compared to the IV group the IC group was more likely to have complete perfusion (Thrombolysis In Myocardial Infarction grade 3 flow) after PCI (risk ratio [RR] 1.08, 95% confidence interval [CI] 1.02 to 1.15). IC administration was associated with similar bleeding rates as IV (RR 0.92, 95% CI 0.68 to 1.24) but with a significant decrease in short-term target vessel revascularization (RR 0.54, 95% CI 0.30 to 0.96). IC administration was also associated with a significant decrease in short-term mortality (RR 0.45, 95% CI 0.23 to 0.90) but this decrease was no longer significant in mid-/long-term RCTs. In conclusion, compared to IV administration IC administration of GPIs has favorable effects on Thrombolysis In Myocardial Infarction flow, target vessel revascularization, and short-term mortality after PCI, with no difference in rates of bleeding. Data regarding mid-/long-term outcomes were limited and inconclusive. Large RCTs with longer follow-up are required to determine long-term safety and efficacy.
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Affiliation(s)
- Sayuri Friedland
- Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital, Lady Davis Institute for Medical Research, McGill University, Montreal, Canada
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Iversen A, Galatius S, Jensen JS. The Optimal Route of Administration of the Glycoprotein IIb/IIIa Receptor Antagonist Abciximab During Percutaneous Coronary Intervention; Intravenous Versus Intracoronary. Curr Cardiol Rev 2011; 4:293-9. [PMID: 20066137 PMCID: PMC2801861 DOI: 10.2174/157340308786349480] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2008] [Revised: 06/02/2008] [Accepted: 06/02/2008] [Indexed: 01/05/2023] Open
Abstract
The use of the glycoprotein (GP) IIb/IIIa receptor antagonist Abciximab has over the years become an important part of the anticoagulant regimen in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Abciximab is a potent inhibitor of platelet aggregation and thrombus formation, but other mechanisms, such as suppression of the inflammatory pathways, have also been proposed to contribute to the benefits of Abciximab. The optimal route of administration, i.e. intravenous versus intracoronary, of the first dose has been questioned, but only tested in small, non-randomised and retrospective studies or studies with short follow-up. No definite conclusion can be made based on these studies. In this review we present the current knowledge published about the intracoronary administration of Abciximab including the mechanisms behind the potential beneficial effects, and the safety. The emphasis will be on clinical trials rather than on studies on the pharmacological mechanisms, as the latter have been reviewed thoroughly elsewhere. Our conclusion from this present review is that randomized trials of intracoronary versus intravenous bolus of Abciximab are needed.
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Affiliation(s)
- Allan Iversen
- Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark
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Rationale and design of the INFUSE-AMI study: A 2 × 2 factorial, randomized, multicenter, single-blind evaluation of intracoronary abciximab infusion and aspiration thrombectomy in patients undergoing percutaneous coronary intervention for anterior ST-segment elevation myocardial infarction. Am Heart J 2011; 161:478-486.e7. [PMID: 21392601 DOI: 10.1016/j.ahj.2010.10.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 10/01/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Whether thrombus aspiration and local glycoprotein IIb/IIIa administration reduce infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) has not been established in multicenter studies. DESIGN INFUSE-AMI is a multicenter, open-label, controlled, single-blind randomized study enrolling 452 subjects with anterior STEMI and an occluded proximal or mid-left anterior descending artery with thrombosis in myocardial infarction 0, 1, or 2 grade flow undergoing primary PCI with bivalirudin anticoagulation. Subjects are randomized in a 2 × 2 factorial to one of the following 4 arms: (1) local infusion of abciximab using the ClearWay RX Local Therapeutic Infusion Catheter (ClearWay, Atrium Medical Corp, Hudson, NH) after aspiration with a 6F Export Aspiration Catheter (Medtronic, Inc, Minneapolis, MN), (2) local infusion of abciximab using the ClearWay RX Infusion Catheter and no aspiration, (3) no local infusion of abciximab and aspiration with a 6F Export Aspiration Catheter, or (4) no local infusion of abciximab and no aspiration. The primary end point is infarct size (percentage of total left ventricular mass) at 30 days measured by cardiac magnetic resonance imaging. Other secondary end points include microvascular obstruction by cardiac magnetic resonance imaging at 5 days, ST-segment resolution, angiographic myocardial perfusion, thrombus burden, angiographic complications, and clinical events through 1-year follow-up. Safety end points include major and minor bleeding. SUMMARY INFUSE-AMI is testing the hypothesis that the intracoronary administration of an abciximab bolus with or without thrombus aspiration before stent implantation compared to no infusion with or without thrombus aspiration reduces infarct size among patients undergoing primary PCI for anterior STEMI who are treated with bivalirudin.
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IVERSEN ALLAN, ABILDGAARD ULRIK, GALLOE ANDERS, HANSEN PETERR, GALATIUS SOREN, MADSEN JANK, ENGSTROEM THOMAS, PEDERSEN SUNE, JENSEN KURTS, JENSEN JANS. Intracoronary Compared to Intravenous Bolus Abciximab during Primary Percutaneous Coronary Intervention in ST-segment Elevation Myocardial Infarction (STEMI) Patients Reduces 30-day Mortality and Target Vessel Revascularization: A Randomized Trial. J Interv Cardiol 2010; 24:105-11. [DOI: 10.1111/j.1540-8183.2010.00616.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Intracoronary Glycoprotein IIb/IIIa Inhibitors. JACC Cardiovasc Interv 2010; 3:935-6. [DOI: 10.1016/j.jcin.2010.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 08/13/2010] [Indexed: 11/24/2022]
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Deibele AJ, Jennings LK, Tcheng JE, Neva C, Earhart AD, Gibson CM. Intracoronary Eptifibatide Bolus Administration During Percutaneous Coronary Revascularization for Acute Coronary Syndromes With Evaluation of Platelet Glycoprotein IIb/IIIa Receptor Occupancy and Platelet Function. Circulation 2010; 121:784-91. [DOI: 10.1161/circulationaha.109.882746] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Eptifibatide reduces major adverse cardiac events in patients with acute coronary syndromes undergoing percutaneous coronary intervention (PCI). Intracoronary bolus administration of eptifibatide may result in higher levels of platelet glycoprotein IIb/IIIa receptor occupancy in the local coronary bed, disaggregate thrombus in the epicardial artery and microvasculature, and thereby improve coronary flow.
Methods and Results—
Patients undergoing PCI for an acute coronary syndrome were randomized to either intracoronary or intravenous bolus administration of eptifibatide. The primary end point was the local glycoprotein IIb/IIIa receptor occupancy measured in the coronary sinus. There were no angiographic, electrophysiological, or other adverse findings attributable to intracoronary eptifibatide. Platelet glycoprotein IIb/IIIa receptor occupancy was significantly greater with intracoronary versus intravenous administration: first bolus, 94±9% versus 51±15% (
P
<0.001); and second bolus, 99±2% versus 91±4% (
P
=0.001), respectively. Microvascular perfusion was significantly improved as measured by the corrected thrombolysis in myocardial infarction frame count (cTFC) with intracoronary versus intravenous administration: pre-PCI, 36 (median) (25th and 75th percentiles, 16 and 64) versus 31 (25th and 75th percentiles, 23 and 45;
P
=0.8); and post-PCI, 18 (25th and 75th percentiles, 10 and 22) versus 25 (25th and 75th percentiles, 22 and 35;
P
=0.007), respectively. The only multivariate predictor associated with a post-PCI cTFC rank score was the first bolus glycoprotein IIb/IIIa receptor occupancy (
P
<0.001).
Conclusions—
Intracoronary bolus administration of eptifibatide during PCI in patients with acute coronary syndromes results in higher local platelet glycoprotein IIb/IIIa receptor occupancy, which is associated with improved microvascular perfusion demonstrated by an improved cTFC.
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Affiliation(s)
- Albert J. Deibele
- From the Duluth Clinic, Division of Cardiology, Duluth, Minn (A.J.D., C.N.); University of Tennessee, Vascular Biology Center of Excellence, Memphis (L.K.J., A.D.E.); Duke University Medical Center, Division of Cardiology, Durham, NC (J.E.T.); and Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, Mass (C.M.G.)
| | - Lisa K. Jennings
- From the Duluth Clinic, Division of Cardiology, Duluth, Minn (A.J.D., C.N.); University of Tennessee, Vascular Biology Center of Excellence, Memphis (L.K.J., A.D.E.); Duke University Medical Center, Division of Cardiology, Durham, NC (J.E.T.); and Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, Mass (C.M.G.)
| | - James E. Tcheng
- From the Duluth Clinic, Division of Cardiology, Duluth, Minn (A.J.D., C.N.); University of Tennessee, Vascular Biology Center of Excellence, Memphis (L.K.J., A.D.E.); Duke University Medical Center, Division of Cardiology, Durham, NC (J.E.T.); and Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, Mass (C.M.G.)
| | - Cathy Neva
- From the Duluth Clinic, Division of Cardiology, Duluth, Minn (A.J.D., C.N.); University of Tennessee, Vascular Biology Center of Excellence, Memphis (L.K.J., A.D.E.); Duke University Medical Center, Division of Cardiology, Durham, NC (J.E.T.); and Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, Mass (C.M.G.)
| | - Angela D. Earhart
- From the Duluth Clinic, Division of Cardiology, Duluth, Minn (A.J.D., C.N.); University of Tennessee, Vascular Biology Center of Excellence, Memphis (L.K.J., A.D.E.); Duke University Medical Center, Division of Cardiology, Durham, NC (J.E.T.); and Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, Mass (C.M.G.)
| | - C. Michael Gibson
- From the Duluth Clinic, Division of Cardiology, Duluth, Minn (A.J.D., C.N.); University of Tennessee, Vascular Biology Center of Excellence, Memphis (L.K.J., A.D.E.); Duke University Medical Center, Division of Cardiology, Durham, NC (J.E.T.); and Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, Mass (C.M.G.)
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Intracoronary versus intravenous abciximab administration in patients with ST-elevation myocardial infarction undergoing thrombus aspiration during primary percutaneous coronary intervention—Effects on soluble CD40 ligand concentrations. Atherosclerosis 2009; 206:523-7. [DOI: 10.1016/j.atherosclerosis.2009.03.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Revised: 02/10/2009] [Accepted: 03/10/2009] [Indexed: 11/19/2022]
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Gu YL, Fokkema ML, Kampinga MA, de Smet BJGL, Tan ES, van den Heuvel AFM, Zijlstra F. Intracoronary versus intravenous abciximab in ST-segment elevation myocardial infarction: rationale and design of the CICERO trial in patients undergoing primary percutaneous coronary intervention with thrombus aspiration. Trials 2009; 10:90. [PMID: 19785725 PMCID: PMC2765937 DOI: 10.1186/1745-6215-10-90] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Accepted: 09/28/2009] [Indexed: 01/09/2023] Open
Abstract
Background Administration of abciximab during primary percutaneous coronary intervention is an effective adjunctive therapy in the treatment of patients with ST-segment elevation myocardial infarction. Recent small-scaled studies have suggested that intracoronary administration of abciximab during primary percutaneous coronary intervention is superior to conventional intravenous administration. This study has been designed to investigate whether intracoronary bolus administration of abciximab is more effective than intravenous bolus administration in improving myocardial perfusion in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention with thrombus aspiration. Methods/Design The Comparison of IntraCoronary versus intravenous abciximab administration during Emergency Reperfusion Of ST-segment elevation myocardial infarction (CICERO) trial is a single-center, prospective, randomized open-label trial with blinded evaluation of endpoints. A total of 530 patients with STEMI undergoing primary percutaneous coronary intervention are randomly assigned to either an intracoronary or intravenous bolus of weight-adjusted abciximab. The primary end point is the incidence of >70% ST-segment elevation resolution. Secondary end points consist of post-procedural residual ST-segment deviation, myocardial blush grade, distal embolization, enzymatic infarct size, in-hospital bleeding, and clinical outcome at 30 days and 1 year. Discussion The CICERO trial is the first clinical trial to date to verify the effect of intracoronary versus intravenous administration of abciximab on myocardial perfusion in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention with thrombus aspiration. Trial registration ClinicalTrials.gov NCT00927615
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Affiliation(s)
- Youlan L Gu
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1 PO Box 30001, 9700 RB Groningen, the Netherlands.
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Effects of intracoronary compared to intravenous abciximab administration in patients undergoing transradial percutaneous coronary intervention: A sub-analysis of the EASY trial. Int J Cardiol 2009; 136:165-70. [DOI: 10.1016/j.ijcard.2008.04.073] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2007] [Revised: 04/05/2008] [Accepted: 04/23/2008] [Indexed: 11/17/2022]
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Tamhane UU, Gurm HS. The chimeric monoclonal antibody abciximab: a systematic review of its safety in contemporary practice. Expert Opin Drug Saf 2008; 7:809-19. [DOI: 10.1517/14740330802500353] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Thiele H, Schindler K, Friedenberger J, Eitel I, Fürnau G, Grebe E, Erbs S, Linke A, Möbius-Winkler S, Kivelitz D, Schuler G. Intracoronary compared with intravenous bolus abciximab application in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: the randomized Leipzig immediate percutaneous coronary intervention abciximab IV versus IC in ST-elevation myocardial infarction trial. Circulation 2008; 118:49-57. [PMID: 18559698 DOI: 10.1161/circulationaha.107.747642] [Citation(s) in RCA: 239] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Abciximab reduces major adverse cardiac events in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI). Intracoronary abciximab bolus application results in high local drug concentrations and may be more effective than a standard intravenous bolus. METHODS AND RESULTS Patients undergoing primary PCI were randomized to either intracoronary (n=77) or intravenous (n=77) bolus abciximab administration with subsequent 12-hour intravenous infusion. The primary end point was infarct size and extent of microvascular obstruction as assessed by delayed enhancement magnetic resonance. Secondary end points were ST-segment resolution at 90 minutes, Thrombolysis in Myocardial Infarction flow and perfusion grades after PCI, and the occurrence of major adverse cardiac events within 30 days. The median infarct size was 15.1% (interquartile range, 6.1% to 25.2%) in the intracoronary versus 23.4% (interquartile range, 13.6% to 33.2%) in the intravenous group (P=0.01). Similarly, the extent of microvascular obstruction was significantly smaller in intracoronary compared with intravenous abciximab patients (P=0.01). Myocardial perfusion measured as early ST-segment resolution was significantly improved in intracoronary patients with an absolute ST-segment resolution of 77.8% (interquartile range, 66.7% to 100.0%) versus 70.0% (interquartile range, 45.2% to 83.5%; P=0.006). The Thrombolysis in Myocardial Infarction flow after PCI was not different between treatment groups (P=0.51), but there was a trend toward an improved perfusion grade (P=0.09). There also was a trend toward a lower major adverse cardiac event rate after intracoronary versus intravenous abciximab application (5.2% versus 15.6%; P=0.06; relative risk, 0.33; 95% CI, 0.09 to 1.05). CONCLUSIONS Intracoronary bolus administration of abciximab in primary PCI is superior to standard intravenous treatment with respect to infarct size, extent of microvascular obstruction, and perfusion.
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Affiliation(s)
- Holger Thiele
- Department of Internal Medicine/Cardiology, University of Leipzig, Heart Center, Strümpellstrasse 39, 04289 Leipzig, Germany.
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Patel SS, Rana H, Mascarenhas DAN. Intracoronary abciximab use in patients undergoing PCI at a community hospital: a single operator experience. J Cardiovasc Pharmacol Ther 2008; 13:89-93. [PMID: 18413897 DOI: 10.1177/1074248408316485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the safety of intracoronary (IC) abciximab during percutaneous coronary intervention (PCI). BACKGROUND Adjunctive treatment with glycoprotein IIb/IIIa inhibitors, especially abciximab, during PCI has been shown to improve clinical and procedural outcomes in numerous studies. However, significant bleeding complications exist with its use and this has limited its standard use. Interest has grown in local (IC) use with studies showing safety and long-term effectiveness, especially in patients with high thrombus loads. METHODS A retrospective review of records in a database of patients who had PCI by a single operator at the Easton Hospital. RESULTS 611 patients received IC abciximab, and there were no complications in 610 (98.3%) patients; only 1 had an allergic reaction. CONCLUSIONS IC abciximab is safe and has a unique role in the catheterization lab and in patients at high risk of bleeding complications who would benefit from its limited use.
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Affiliation(s)
- Sandeep S Patel
- Department of Cardiology, Mt. Sinai Medical Center/Bronx VA, Bronx, New York, USA
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Hassan W, Al-Sergani H, Al Buraiki J, Dunn B, Al Turki F, Akhras N, Elshaer F, Nawaz M, Kharabsheh S, ElKum N. Immediate and intermediate results of intracoronary stand-alone bolus administration of eptifibatide during coronary intervention (ICE) study. Am Heart J 2007; 154:345-51. [PMID: 17643587 DOI: 10.1016/j.ahj.2007.04.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2006] [Accepted: 04/08/2007] [Indexed: 01/13/2023]
Abstract
BACKGROUND This study evaluated the immediate and intermediate results of intracoronary (i.c.) eptifibatide administration during percutaneous coronary intervention (PCI). Several studies tested intravenous (i.v.) bolus and continuous administration of eptifibatide during PCI. However, limited data are available regarding giving eptifibatide as i.c. bolus alone during PCI. METHODS We studied clinical outcomes of 376 patients who received coronary stent(s) and eptifibatide by 3 applications during PCI and were followed up over 24 months. Group A (119 patients) had i.c. eptifibatide bolus only, group B (119 patients) had i.c. bolus and i.v. infusion, and group C (138 patients) had i.v. bolus and infusion. The standard 2 boluses of eptifibatide 180 microg/kg were given either via i.c. or i.v. route, and only groups B and C received i.v. infusion at 2 microcg x kg(-1) x min(-1) for 18 to 24 hours. RESULTS There were 256 males and 120 females, with a mean age of 57 +/- 11 years. Among them, 52% were diabetic. The 6-, 12-, and 24-month cumulative composite end point of death and myocardial infraction was lower in group A (2.5%) compared with group C (10.8%, odds ratio [OR] 4.3, P = .029) and group B (5.8%, OR 2.6, P = .17). Compared with group A, target vessel revascularization was 3-fold in group C (OR 3.3, P = .001) and 2-fold in group B (OR 2.0, P = .061). Bleeding was significantly higher in group C (OR 5.4, P < .0001) and group B (OR 3.4, P = .007) compared with group A. Rehospitalization was significantly lower in group A (10.9%) compared with group B (16.8%) and group C (28%) (P = .0009). CONCLUSION The i.c.-bolus-alone application of eptifibatide may be safer and superior to the i.v. route, and continuous infusion may not be necessary. Large-scale prospective randomized trials are needed to further validate these findings.
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Affiliation(s)
- Walid Hassan
- King Faisal Heart Institute, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
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Carey BC, Blankenship JC. A sequential approach to the management of a massive intracoronary thrombus in ST elevation myocardial infarction: a case report. Angiology 2007; 58:106-11. [PMID: 17351166 DOI: 10.1177/0003319706295511] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Thrombus-laden coronary lesions present a particular challenge to the interventional cardiologist. Despite the development of multiple strategies to attack this problem, lesions with angio-graphically visible thrombus still carry a high risk of complications when coronary intervention is attempted. The authors present a case of acute inferior ST elevation myocardial infarction with a massive thrombus in an ectatic right coronary artery. Sequential treatment with intra-coronary glycoprotein IIb/IIIa inhibitor, rheolytic thrombectomy with 2 different-sized catheters, and transcatheter thrombus aspiration with a Pronto aspiration catheter was required to achieve a satisfactory result. This case illustrates the potential benefit of combining various mechanical strategies to treat intracoronary thrombus.
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Affiliation(s)
- Brian C Carey
- Department of Cardiology, Geisinger Medical Center, Danville, PA 17822, USA.
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Romagnoli E, Burzotta F, Trani C, Biondi-Zoccai GGL, Giannico F, Crea F. Rationale for intracoronary administration of abciximab. J Thromb Thrombolysis 2006; 23:57-63. [PMID: 17160551 DOI: 10.1007/s11239-006-9000-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The present review aims to describe the pharmacological aspects as well as the available clinical data supporting the choice of intracoronary route of administration for abciximab, an antiplatelet drug used in patients with acute coronary syndromes undergoing percutaneous coronary interventions (PCI). Abciximab is a glycoprotein (GP) IIb/IIIa receptor antagonist which determines a potent inhibition of platelet aggregation and thrombus formation. These properties seem to prevent not only thrombus formation but also to promote (at higher drug concentration) lysis of fresh thrombus. Moreover, differently from the other GP IIb/IIIa inhibitors, abciximab also binds to the vitronectin receptor on endothelial, smooth muscle, and inflammatory cells and to an activated conformation of the aMb2 receptor on leukocytes. Such cross-reactivity raises the possibility that clinical benefits derived from its use may not be exclusively due to its anti-thrombotic effect, but may also be related to the suppression of inflammatory pathways involving platelets, white blood cells, and the vascular endothelium. On such basis, the local administration of abciximab at the site of coronary thrombosis may enhance, by increasing its local concentration, the binding to both platelet and endothelium receptors. The results of several angiographic studies assessing the effect of intracoronary abciximab administration support on clinical grounds its adoption in patients with fresh coronary thrombosis. Indeed, better post-angioplasty coronary flow, greater degree of myocardial salvage and a better left ventricular function recovery have been achieved as compared to the intravenous, systemic, administration of drug's bolus. Condensed Abstract Several studies have highlighted the benefits of abciximab, a potent antiplatelet agent, in patients with acute coronary syndromes undergoing percutaneous coronary interventions. Moreover, differently from the other glycoprotein IIb/IIIa receptor antagonists, abciximab also has non-IIb/IIIa-related properties raising the possibility that clinical benefits derived from its use may not be exclusively due to its anti-thrombotic effect, but may also be related to the suppression of inflammatory pathways. Several angiographic studies in patients with fresh coronary thrombosis and recent clinical studies in patients with acute coronary syndromes undergoing mechanical revascularization support the hypothesis that local administration of abciximab at the site of the culprit coronary artery may facilitate both the de-thrombotic and the non-GP IIb/IIIa-dependent properties of the drug. On such basis, the present review aims to describe the pharmacological aspects as well as the available clinical data supporting the choice of intracoronary route of administration for abciximab.
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Affiliation(s)
- Enrico Romagnoli
- Department of cardiovascular disease, Catholic University, Campobasso, Italy.
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Deibele AJ, Kirtane AJ, Pinto DS, Lucca MJ, Neva C, Shui A, Murphy SA, Tcheng JE, Gibson CM. Intracoronary bolus administration of eptifibatide during percutaneous coronary stenting for non ST elevation myocardial infarction and unstable angina. J Thromb Thrombolysis 2006; 22:47-50. [PMID: 16786232 DOI: 10.1007/s11239-006-7454-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Distal embolization of thrombotic debris may occur during and after percutaneous coronary intervention (PCI) for acute coronary syndromes. This may lead to impaired microvascular perfusion, myocardial infarction and increased morbidity and mortality. In vitro studies suggest that high local concentrations of a glycoprotein IIb/IIIa inhibitor may be effective in disaggregating thrombus and thereby prevent microvascular compromise. We hypothesized that intracoronary (IC) administration of eptifibatide during stent implantation for unstable angina/non ST elevation myocardial infarction (UA/NSTEMI) would be safe and would lead to an acceptable rate of normal myocardial perfusion. METHODS In 54 patients with UA/NSTEMI, 2 boluses of 180 mcg/kg of eptifibatide each were administered via the IC route during PCI. Data were retrospectively collected and reviewed by an independent core laboratory. RESULTS No adverse events including arrhythmias occurred during IC administration of eptifibatide. There were no deaths or urgent revascularizations among patients treated with IC eptifibatide. One patient (2.0%) sustained a post-procedure myocardial infarction. One patient sustained a TIMI major bleeding event due to a gastrointestinal bleed. There were no TIMI minor bleeding events. Normal post PCI TIMI Myocardial Perfusion Grade was observed in 54% of patients. CONCLUSION IC bolus administration of eptifibatide was feasible and safe among patients with UA/NSTEMI. Larger prospective and randomized studies are warranted to further explore the efficacy of this strategy. Intracoronary eptifibatide administration during PCI for UA/NSTEMI is feasible and safe.
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Germing A, Mügge A, Lindstaedt M. Recurrent myocardial ischemia due to riding left main coronary artery bifurcation thrombus--noninterventional therapy with glycoprotein blocker and thrombolysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2006; 7:76-80. [PMID: 16757405 DOI: 10.1016/j.carrev.2005.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Revised: 11/10/2005] [Accepted: 11/10/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND Acute coronary syndrome (ACS) comprises different manifestations of coronary artery disease. Angiograms performed at the time of an ACS may present different coronary morphologies; mostly there are acute vessel occlusions, ruptured atherosclerotic plaques, or thrombotic lesions that require reperfusion therapy. In the presence of intracoronary thrombi localized in the left main coronary artery, the clinical situation is challenging. Hemodynamic situation, symptoms, and rhythm status may change immediately and entail high mortality. Catheter-based therapy and surgical revascularization are associated with a high mortality rate. A noninterventional approach may be chosen in patients with stable hemodynamics and reestablished perfusion. METHODS AND PATIENT We describe a patient with acute ST-elevation myocardial infarction with chest pain and stable hemodynamics. Angiography revealed a large thrombus in the left main coronary artery bifurcation with ostial subtotal narrowing of the circumflex and left anterior descending artery. However, coronary perfusion was maintained. Immediate treatment with the glycoprotein IIb/IIIa inhibitor abciximab was performed. The patient became asymptomatic. Angiography the next day showed no change in thrombus formation, so abciximab infusion was prolonged. Initial elevated enzymes decreased to normal values. Three days later the patient developed a new unstable angina with newly elevated cardiac enzymes. At this time, a thrombolytic agent was administered. Angiography 2 days later demonstrated normal coronaries. CONCLUSION This case demonstrates the impact of intracoronary thrombi on repetitive myocardial ischemia and the effectiveness of a noninterventional pharmacological approach for the treatment of acute myocardial infarction due to intracoronary thrombus even in the left main coronary bifurcation.
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Affiliation(s)
- Alfried Germing
- Medical Clinic II, Cardiology and Angiology, BG-Kliniken Bergmannsheil, University of Bochum, 44789 Bochum, Germany.
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Galache Osuna JG, Sánchez-Rubio J, Calvo I, Diarte JA, Lukic A, Placer LJ. ¿Mejora el uso de abciximab intracoronario el resultado del intervencionismo percutáneo? Estudio prospectivo y aleatorizado. Rev Esp Cardiol 2006. [DOI: 10.1157/13090138] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Morrison DA, Thai H, Goldman S, Felix E, Hernandez J. Percutaneous coronary intervention of or through saphenous vein grafts or internal mammary arteries: the impact of stents, adjunctive pharmacology, and multicomponent distal protection. Catheter Cardiovasc Interv 2006; 67:571-9. [PMID: 16547927 DOI: 10.1002/ccd.20641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We hypothesized that the use of stents and aggressive adjunctive pharmacotherapies has been associated with lower rates of complicating myocardial infarction (MI) and improved long-term outcomes compared to either previous balloon-only percutaneous coronary intervention (PCI) or atheroablative intervention for lesions of or through saphenous vein grafts (SVGs) and/or internal mammary arteries (IMAs). PCI of SVG has been complicated by relatively high rates of procedural MI and less favorable long-term outcomes than native vessel PCI, stimulating the development and application of an array of technologies. This study was based on retrospective review of stent-era (1999-2004) 5-year experience of a single center with 95 SVG procedures in 85 patients and 20 IMA procedures in 20 patients. These cases were compared with the previously published experience of one of the operators during the balloon-only period and literature review of the application of multiple technologies to SVG intervention, as well as consideration of the reoperation alternative. There was one in-hospital death each in the SVG cohort (1%) and in the IMA cohort (5%). There were SIX procedural MIs (6%), defined by total CK > normal, and 19 procedural MIs (20%) based on troponin-I > 1.0. Follow-up has been from 4 months to 5 years (average, 2.5 years), with 91% survival and one late CABG in the IMA group. SVG PCI with stents and adjunctive pharmacotherapies is associated with relatively low rates of procedural MI and favorable long-term outcomes.
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Affiliation(s)
- Douglass A Morrison
- Section of Cardiology, Department of Internal Medicine, SAVAHCS, and the University of Arizona, Sarver Heart Center, Tucson, 85723, USA.
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Romagnoli E, Burzotta F, Trani C, Mazzari MA, Biondi-Zoccai GGL, De Vita M, Giannico F, Niccoli G, Prati F, Rebuzzi AG, Mongiardo R, Crea F. Angiographic evaluation of the effect of intracoronary abciximab administration in patients undergoing urgent PCI. Int J Cardiol 2005; 105:250-5. [PMID: 16274764 DOI: 10.1016/j.ijcard.2004.11.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2004] [Accepted: 11/13/2004] [Indexed: 02/05/2023]
Abstract
BACKGROUND Recent data suggest that the intracoronary (i.c.) administration of a systemic bolus dose of abciximab during PCI may increase the efficacy of this antiplatelet drug. However, the effect of i.c. abciximab on coronary angiographic flow has been not clarified. METHODS We studied 37 consecutive patients with acute coronary syndromes (ACS) who underwent successful urgent PCI on the target vessel and were treated by an i.c. abciximab bolus (0.25 mg/kg) prior to the first balloon inflation (Group IC), and 37 matched controls who were treated by intravenous (i.v.) abciximab bolus at the same dose (Group IV). Corrected TIMI frame count (CTFC) in the culprit and in a non-culprit coronary artery branch was assessed before treatment, immediately after intracoronary administration of abciximab bolus and at the end of the procedure. RESULTS After administration of abciximab, CTFC significantly decreased from 48+37 to 33+30 (P=0.001) in the culprit vessel while in the non-culprit vessel it remained unchanged (16+7 pre-treatment and 16+7 post-treatment, P=0.68). Final CTFC was 12+4 in Group IC and 14+5 in Group IV (P=0.069). Post-treatment mean peak of the cardiac enzymes showed a trend toward reduction in Group IC compared with Group IV. CONCLUSIONS The i.c. administration of abciximab bolus acutely decreases CTFC through culprit vessels of patients with ACS undergoing urgent PCI. Further studies evaluating the potential clinical benefits associated with i.c. abciximab administration are warranted.
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Affiliation(s)
- Enrico Romagnoli
- Institute of Cardiology, Catholic University, Largo A. Gemelli 8, 00168 Rome, Italy.
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