Combined Abciximab REteplase Stent Study in acute myocardial infarction (CARESS in AMI)

[Pharmacoinvasive Approach to the Treatment of Acute ST-Segment Elevation Myocardial Infarction. Current State of the Problem]

The articled focused on the pharmacoinvasive approach to the treatment of acute ST-segment elevation myocardial infarction. Current guidelines prioritize the primary transcutaneous coronary intervention. However, in both the Russian Federation and other countries, there are some peculiarities (logistic issues, specific aspects of infrastructure of medical facilities), which may hamper timely conduction of the endovascular treatment. In such cases, the thrombolytic therapy subsequently supplemented with transcutaneous coronary intervention would appear the most effective strategy aimed at the earliest recovery of coronary perfusion. The authors provided results of major studies that used such approach and the effect of using the thrombolytic therapy with recombinant prourokinase, a Russian third generation thrombolytic drug.

Percutaneous Coronary Intervention after Fibrinolysis for ST-Segment Elevation Myocardial Infarction Patients: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Percutaneous coronary intervention (PCI), fibrinolysis and the combination of both methods are current therapeutic options for patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

We searched PubMed, EMBASE, Google scholar and Cochrane Controlled Trials Register for randomized controlled trials (RCTs) evaluating the efficacy and safety of PCI after fibrinolysis within 24 hours, which was compared with primary PCI alone and ischemia-guided or delayed PCI. Meta-analysis was conducted using Review Manager 5.30 following the methods described by the Cochrane library.

RESULTS

A total of 16 studies including 10,034 patients were enrolled. As compared with primary PCI alone group, the short-term mortality (5.8% vs 4.5%, RR 1.29, 95% confidence interval [CI] 1.00-1.65) and re-infarction rate (4.1% vs 2.7%, RR 1.46, 95%CI 1.05-2.03) were higher in the immediate PCI group (median/mean time ≤ 2 h after fibrinolysis). However, the short-term mortality and re-infarction rate showed no statistically significant differences in the early PCI group (2-24 hours after fibrinolysis). The rate of major bleeding events was higher both in the immediate PCI (6.3% vs 4.4%, RR 1.43, 95%CI 1.11-1.85) and the early PCI group (6.4% vs 4.4%, RR 1.46, 95%CI 1.03-2.06) as compared with primary PCI alone group. As compared with ischemia-guided or delayed PCI, early PCI was associated with significantly reduced re-infarction (2.4% vs 4.0%, RR 0.61, 95%CI 0.41-0.92) and recurrent ischemia (1.5% vs 5.3%, RR 0.29, 95%CI 0.12-0.70) at short-term. And the reduced re-infarction rate was also observed at long-term.

CONCLUSIONS

Early PCI after fibrinolysis, with a relatively broader time for PCI preparation, can bring the similar effects with primary PCI alone and is better than ischemia-guided or delayed PCI in STEMI patients with symptom onset < 12 h who cannot receive timely PCI. However, immediate PCI after fibrinolysis is detrimental.

Association of initial thrombolysis in myocardial infarction flow grade with mortality among patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: a National Registry of Myocardial Infarction-5 (NRMI-5) analysis

BACKGROUND

Initial epicardial coronary flow, as assessed by the Thrombolysis in Myocardial Infarction flow grade (TFG), prior to primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI) has been associated with short- and long-term mortality in randomized clinical trials. This study was designed to determine the relationship between initial TFG and mortality in a large, heterogeneous, real-world population of STEMI patients undergoing pPCI.

METHODS

The relationship between pre-pPCI TFG among patients undergoing pPCI and in-hospital mortality was evaluated among STEMI patients from 2004 to 2006 in the National Registry of Myocardial Infarction.

RESULTS

Of 8,337 STEMI patients, 6,595 (79.1%) had pre-pPCI TFG 0/1, 1,126 (13.5%) had pre-pPCI TFG 2, and 616 (7.4%) had pre-pPCI TFG 3. TFG 0/1 prior to pPCI was associated with 3.4% in-hospital mortality, whereas TFG 2 (2.0%) and TFG 3 (1.8%) were associated with significantly lower mortality (TFG 0/1 vs TFG 2, P = .013; TFG 0/1 vs TFG 3, P = .035). TFG 0/1 prior to pPCI was also associated with a significant increase in the composite of death, recurrent myocardial infarction, heart failure, and shock (16.1%) when compared with patients presenting with TFG 2 (11.5%; P < .001) and TFG 3 (7.6%; P < .001). The difference in this composite was also significant between patients presenting with TFG 2 and TFG 3 (P = .01).

CONCLUSIONS

In a large, heterogeneous group of real-world patients presenting with STEMI, pre-pPCI TFG 0/1 is associated with higher in-hospital mortality and other major adverse cardiovascular events. These results corroborate prior to post hoc analyses from randomized clinical trials and support continued efforts aimed at safely establishing early infarct-related artery patency among patients with STEMI.

Comparison of epicardial and myocardial perfusions after primary coronary angioplasty for ST-elevation myocardial infarction in patients under and over 75 years of age

BACKGROUND AND AIMS

Patients aged ≥75 years compose a high-risk subgroup for acute myocardial infarction (AMI). It is unknown whether myocardial perfusion in these patients is decreased compared with younger ones after primary percutaneous coronary intervention (PPCI), which may contribute to their worse prognosis. We compared epicardial and myocardial perfusions as well as short-term outcomes between elderly and younger patients undergoing PPCI.

METHODS

A total of 547 consecutive PPCI patients were prospectively enrolled; of these, 106 were elderly (≥75 yrs). Epicardial perfusion was evaluated by the Thrombolysis in Myocardial Infarction (TIMI) flow grade and corrected TIMI frame count (CTFC), and myocardial perfusion was evaluated by the TIMI myocardial perfusion grade (TMPG) and ST-segment resolution (STR).

RESULTS

Despite comparable epicardial perfusion pre- and post-PPCI, elderly patients had impaired myocardial perfusion after PPCI, as measured by reduced TMPG (35.9% vs 14.5%, p=0.001) and absent STR (18.9% vs 9.8%, p=0.009). After adjusting for clinical and angiographic risk profiles, multivariate analysis showed that age ≥75 years remained independently associated with reduced TMPG or absent STR. In the whole population, multivariate analysis revealed that both age ≥75 years and absent STR were independently associated with 3-month major adverse cardiac events (MACE). In the elderly subgroup, multivariate analysis identified absent STR as the strongest determinant of 3-month MACE.

CONCLUSIONS

Age is associated with impaired myocardial perfusion, but not epicardial perfusion, after PPCI for AMI. To further improve the outcome of elderly AMI patients, efforts should be aimed at improving myocardial perfusion beyond epicardial recanalization.

The NORwegian study on DIstrict treatment of ST-Elevation Myocardial Infarction (NORDISTEMI)

OBJECTIVES

Thrombolysis is the treatment of choice for patients with ST-elevation myocardial infarction (STEMI) living in rural areas with long transfer delays to percutaneous coronary intervention (PCI). This trial compares two different strategies following thrombolysis: to transfer all patients for immediate coronary angiography and intervention, or to manage the patients more conservatively.

DESIGN

The NORwegian study on DIstrict treatment of STEMI (NORDISTEMI) is an open, prospective, randomized controlled trial in patients with STEMI of less than 6 hours of duration and more than 90 minutes expected time delay to PCI. A total of 266 patients will receive full-dose thrombolysis, preferably pre-hospital, and then be randomized to either strategy. Our primary endpoint is the one year combined incidence of death, reinfarction, stroke or new myocardial ischaemia. The study is registered with ClinicalTrials.gov, number NCT00161005.

RESULTS

By April 2006, 109 patients have been randomized. Thrombolysis has been given pre-hospital to 52% of patients. The median transport distance from first medical contact to catheterization laboratory was 155 km (range 90-396 km). Results of the study are expected in 2008.

Shifting from pharmacological to systematic mechanical reperfusion therapy for acute myocardial infarction via a cooperating network: impact on reperfusion rate and in-hospital mortality

BACKGROUND

Primary percutaneous transluminal coronary angioplasty is the preferred reperfusion strategy for acute ST-elevation myocardial infarction in selected settings. Limited data are available about the clinical impact of the implementation of a systematic primary angioplasty infarct reperfusion program in the real world.

METHODS AND RESULTS

We organized a comprehensive district network allowing the coordinated and timely transfer of patients with acute ST-elevation myocardial infarction to the hub hospital with catheterization facilities in order to expand the use of mechanical reperfusion. Implementation of the network resulted in increased numbers of patients receiving reperfusion therapies (from 57.5% to 74.1%; P < 0.001). In addition, the proportion of elderly individuals (those aged > or = 75 years) who received a reperfusion therapy significantly increased (from 25.7% to 66.3%; P < 0.001). Accordingly, the proportion of patients not receiving reperfusion therapy dropped from 42.5% to 25.9%. Primary percutaneous transluminal coronary angioplasty usage increased from 24.5% to 73.1% (P < 0.001). As a consequence, in-hospital mortality decreased from 13.5% before establishment of the network to 6.0% (P = 0.016), and major adverse cardiac events decreased from 17.5% to 7.8% (P = 0.005).

CONCLUSIONS

Implementation of a systematic primary angioplasty infarct reperfusion program improves reperfusion rate and reduces in-hospital mortality and total major adverse cardiovascular events.

Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial

BACKGROUND

Thrombolysis remains the treatment of choice in ST-segment elevation myocardial infarction (STEMI) when primary percutaneous coronary intervention (PCI) cannot be done within 90 min. However, the best subsequent management of patients after thrombolytic therapy remains unclear. To assess the best management, we randomised patients with STEMI treated by thrombolysis and abciximab at a non-interventional hospital to immediate transfer for PCI, or to standard medical therapy with transfer for rescue angioplasty.

METHODS

600 patients aged 75 years or younger with one or more high-risk features (extensive ST-segment elevation, new-onset left bundle branch block, previous myocardial infarction, Killip class >2, or left ventricular ejection fraction < or =35%) in hospitals in France, Italy, and Poland were treated with half-dose reteplase, abciximab, heparin, and aspirin, and randomly assigned to immediate transfer to the nearest interventional centre for PCI, or to management in the local hospital with transfer only in case of persistent ST-segment elevation or clinical deterioration. The primary outcome was a composite of death, reinfarction, or refractory ischaemia at 30 days, and analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number 00220571.

FINDINGS

Of the 299 patients assigned to immediate PCI, 289 (97.0%) underwent angiography, and 255 (85.6%) received PCI. Rescue PCI was done in 91 patients (30.3%) in the standard care/rescue PCI group. The primary outcome occurred in 13 patients (4.4%) in the immediate PCI group compared with 32 (10.7%) in the standard care/rescue PCI group (hazard ratio 0.40; 95% CI 0.21-0.76, log rank p=0.004). Major bleeding was seen in ten patients in the immediate group and seven in the standard care/rescue group (3.4%vs 2.3%, p=0.47). Strokes occurred in two patients in the immediate group and four in the standard care/rescue group (0.7%vs 1.3%, p=0.50).

INTERPRETATION

Immediate transfer for PCI improves outcome in high-risk patients with STEMI treated at a non-interventional centre with half-dose reteplase and abciximab.

Time to treatment and ST-segment resolution in high-risk patients with acute myocardial infarction transferred from community hospitals for coronary angioplasty after pharmacological treatment

OBJECTIVE

To evaluate the impact of symptom-onset-to-balloon delay on ST-segment resolution (STR) in patients with acute myocardial infarction transferred from community hospitals for angioplasty after pharmacological treatment. The study design was prospective, single centre registry.

METHODS

Between October 2000 and December 2003, 330 consecutive patients aged < or =75 years with high-risk myocardial infarction were considered; 193 patients underwent primary percutaneous coronary intervention (PCI) (group P), whereas 137 patients were given pharmacological therapy and were immediately transferred to the hospital with PCI facilities (group F).

RESULTS

Compared with group P, group F showed a longer time to treatment (253 +/- 136 vs. 195 +/- 141 min; P < 0.0001) and a higher percentage of Thrombolysis In Myocardial Infarction flow grade 2-3 at pre-PCI angiography (107 [78.1%] vs. 48 [24.8%]; P < 0.0001). The rate of STR > or =70% was similar in groups P and F (121 [62.7%] vs. 94 [68.6%]; P = 0.41). Even after accounting for baseline variables, STR <70% was not significantly related to the transfer strategy (adjusted hazard ratio 0.94, 95% confidence interval 0.94-1.77; P = 0.8). Patients with incomplete STR showed a higher six-month mortality compared with patients with complete STR (10 [8.85%] vs. 6 [2.76%]; P = 0.027).

CONCLUSIONS

The STR index predicts survival in patients with ST-elevation myocardial infarction treated with angioplasty either directly or after pharmacological treatment and hospital transfer. Pharmacological facilitation seems to be able to counterbalance the negative consequences of the transfer-related time delay on myocardial reperfusion as evaluated by the STR index.

Rationale and design of the Trial of Routine ANgioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI)

BACKGROUND

Most patients with ST-elevation myocardial infarction present to hospitals without percutaneous coronary intervention (PCI) facilities and receive fibrinolysis. The role of routine early PCI after fibrinolysis, using stents and contemporary pharmacotherapy, has not been studied in a large adequately powered randomized trial.

OBJECTIVE

To compare a pharmacoinvasive strategy of transfer for routine PCI within 6 hours after fibrinolysis with standard treatment after fibrinolysis (including predefined criteria for rescue PCI and delayed cardiac catheterization for patients who do not require rescue PCI).

METHODS

A total of 1200 patients with high-risk ST-elevation myocardial infarction presenting to non-PCI centers will be randomized to a pharmacoinvasive strategy (transfer for routine PCI within 6 hours of fibrinolysis) or to standard treatment after fibrinolysis. The primary end point is the 30-day composite of death, reinfarction, recurrent ischemia, heart failure, or shock.

RESULTS

More than 900 patients have been enrolled as of April 2007. An interim safety analysis of the first 536 patients demonstrated no safety concerns. Enrolment is expected to be completed in late 2007.

CONCLUSIONS

This study will provide important data on whether routine early PCI within 6 hours after fibrinolysis is safe and superior to the standard treatment of fibrinolysis with rescue PCI or delayed cardiac catheterization.

New trials and therapies for acute myocardial infarction

Acute coronary syndromes (ACSs), which include the clinical entities of unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI), account for more than 1.5 million hospital admissions annually in the United States alone. Approximately 1 million of these admissions are classified as UA/NSTEMI and approximately 500,000 are STEMI. Because of the overwhelming number of studies on ACSs over the past several years, this article focuses on new trials and therapies for treating patients diagnosed with STEMI.

Update and rationale for ongoing acute myocardial infarction trials: combination therapy, facilitation, and myocardial preservation

Advancements in the treatment of myocardial infarction such as coronary care units, patient education, improved emergency response systems, and reperfusion therapy have reduced mortality. However, in an effort to further reduce the present rate by improving patency rates and microcirculatory perfusion, by better preserving myocardium, and/or treating shock more effectively, more research is under way to improve strategies now in place and to develop new, more effective ways to treat these patients.

Immediate angioplasty after thrombolysis: a systematic review

BACKGROUND

The role of immediate transfer for percutaneous coronary intervention (PCI) after thrombolysis for ST-segment elevation myocardial infarction remains controversial. We performed a systematic review of the related literature to determine whether thrombolysis followed by transfer for immediate or early PCI is safe, feasible and superior to conservative management.

METHODS

A systematic literature search of MEDLINE, EMBASE, the Cochrane Database for Systematic Reviews and Cochrane Central Register of Controlled Trials, and the American Heart Association EndNote 7 Master Library databases, was performed to 2004 for relevant published studies. The level of evidence and the quality of the study design and methods were rated by 2 reviewers according to a standardized classification. A quantitative meta-analysis was performed to assess the effect at 6-12 months on mortality of immediate or early PCI after thrombolysis.

RESULTS

We found 13 articles that were supportive of immediate or early PCI after thrombolysis and 16 that were neutral or provided evidence opposing it. The largest randomized trials and meta-analyses showed no benefit of routine PCI immediately or shortly after thrombolysis. The studies that were supportive were generally more recent and more frequently involved coronary stents. One large trial supported early PCI after thrombolysis for patients with myocardial infarction complicated by cardiogenic shock. Overall, the difference in mortality rates between the invasive strategy and conservative care was nonsignificant. The 3 stent-era trials showed a significantly lower mortality among patients randomly assigned to the invasive strategy (5.8% v. 10.0%, odds ratio 0.55, 95% confidence interval 0.32-0.92). Analysis of variance found a significant difference in treatment effect between stent-era and pre-stent-era trials.

INTERPRETATION

At present, there is inadequate evidence to recommend routine transfer of patients for immediate or early PCI after successful thrombolysis. Results of recent trials using contemporary PCI techniques, including coronary stents, appear more favourable but need to be confirmed in large randomized trials, which are currently in progress. Transfer for immediate PCI is recommended for patients with cardiogenic shock, hemodynamic instability or persistent ischemic symptoms after thrombolysis.

Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients

AIMS

Although outcomes after acute myocardial infarction (AMI) seemed to be superior with primary percutaneous coronary intervention (PPCI) relative to fibrinolysis (FL), the extent to which treatment delay modulates this treatment effect is unclear.

METHODS AND RESULTS

Twenty-five randomized trials (n = 7743) testing the efficacy of PPCI vs. FL were identified in journal articles and abstract listings published between 1990 and 2002. Of these, individual patient data from 22 trials (n = 6763) were pooled, and multi-level logistic regression assessed the relationship among treatment, treatment delay, and 30-day mortality. Treatment delay was divided into 'presentation delay' [symptom onset to randomization; FL: median 143 (IQR: 91-225) min; PPCI: 140 (91-220) min] and hospital-specific 'PCI-related delay' [median time from randomization to PPCI minus median time to FL per hospital; median 55 (IQR: 37-74) min]. PPCI was associated with a significant 37% reduction in 30-day mortality [adjusted OR, 0.63; 95% CI (0.42-0.84)]. Although, there was no heterogeneity in the treatment effect by presentation delay (pBreslow-Day = 0.88), the absolute mortality reduction by PPCI widened over time (1.3% 0-1 h to 4.2% >6 h after symptom onset). When the PCI-related delay was <35 min, the relative (67 vs. 28% pBreslow-Day = 0.004) and absolute (5.4 vs. 2.0%) mortality reduction was significantly higher than those with longer delays.

CONCLUSION

PPCI was associated with significantly lower 30-day mortality relative to FL, regardless of treatment delay. Although logistic and economic constraints challenge the feasibility of 'PPCI-for-all', the benefit of timely treatment underscores the importance of a comprehensive, unified approach to delivery of cardiac care in all AMI patients.

Implementation of reperfusion therapy in acute myocardial infarction. A policy statement from the European Society of Cardiology

Reperfusion therapy in ST-segment elevation myocardial infarction (STEMI) is the most important component of treatment, as it strongly influences short- and long-term patient outcome. The main objective of healthcare providers should be to achieve at least 75% of reperfusion therapy applied to patients suffering from STEMI in a timely manner, and preferably within the first 3 h after onset of symptoms. Establishing networks of reperfusion at regional and national level, implying close collaboration between all the actors involved in reperfusion therapy, namely hospitals, departments of cardiology, PCI centres, emergency medical systems (EMS), (para)medically staffed ambulances, private cardiologists, primary care physicians, etc., is a key issue. All forms of reperfusion, depending on local facilities, need to be available to patients. Protocols must be written and agreed for the strategy of reperfusion to be applied within a network. Early diagnosis of STEMI is essential and is best achieved by rapid ECG recording and interpretation at first medical contact, wherever this contact takes place (hospital or ambulance). Tele-transmission of ECG for immediate interpretation by experienced cardiologists is an alternative. Primary PCI is the preferred reperfusion option if it can be performed by experienced staff within 90 min after first medical contact. Thrombolytic treatment, administered if possible in the pre-hospital setting, is a valid option if PCI cannot be performed in a timely manner, particularly within the first 3 h following onset of symptoms. Thrombolysis is not the end of the reperfusion therapy. Rescue PCI must be performed in the case of thrombolysis failure. Next-day PCI after successful thrombolysis has been proven efficacious. Quality control is important for monitoring the efficacy of networks of reperfusion. All elements that influence time to reperfusion must be taken into account, particularly transfer delays, in-hospital delays, and door-to-balloon or door-to-needle times. The rate of reperfusion achieved must also be taken into consideration. Professional organizations such as the European Society of Cardiology (ESC) have the responsibility to impart this message to the cardiology community, and inform politicians and health authorities about the best possible strategy to achieve reperfusion therapy.

Coronary stenting and abciximab in primary angioplasty for ST-segment-elevation myocardial infarction

Advances in anti-platelet therapy and improvement of stent deployment techniques have improved the safety and efficacy of stenting in the setting of ST-segment-elevation myocardial infarction (STEMI). However, in randomized trials, routine coronary stenting does not reduce mortality and re-infarction, compared to balloon angioplasty. Further, the benefits in target vessel revascularization seem to be reduced when applied to unselected patients with STEMI. Direct stenting represents an attractive strategy with potential benefits in terms of myocardial perfusion. Future large randomized trials are needed to evaluate whether this strategy has a significant impact on outcome, and to provide a cost-benefit analysis of the unrestricted use of drug-eluting stents in this high-risk subset of patients. The additional use of abciximab reduces mortality in primary angioplasty. Since the feasibility of long-distance transportation has been shown in several randomized trials, early pharmacological pre-treatment may confer further advantages by early recanalization and shorter ischaemic time, particularly in high-risk patients. Further randomized trials are needed to clarify the potential benefits from early abciximab administration and the potential role of small molecules in primary angioplasty for STEMI.

Combined Angioplasty and Pharmacological Intervention Versus Thrombolysis Alone in Acute Myocardial Infarction (CAPITAL AMI Study)

OBJECTIVES

We compared a strategy of tenecteplase (TNK)-facilitated angioplasty with one of TNK alone in patients presenting with high-risk ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Previous trials show that thrombolysis followed by immediate angioplasty for the treatment of STEMI does not improve ischemic outcomes compared with thrombolysis alone and is associated with excessive bleeding complications. Since the publication of these trials, however, significant pharmacological and technological advances have occurred.

METHODS

We randomized 170 patients with high-risk STEMI to treatment with TNK alone (84 patients) or TNK-facilitated angioplasty (86 patients). The primary end point was a composite of death, reinfarction, recurrent unstable ischemia, or stroke at six months.

RESULTS

At six months, the incidence of the primary end point was 24.4% in the TNK-alone group versus 11.6% in the TNK-facilitated angioplasty group (p = 0.04). This difference was driven by a reduction in the rate of recurrent unstable ischemia (20.7% vs. 8.1%, p = 0.03). There was a trend toward a lower reinfarction rate with TNK-facilitated angioplasty (14.6% vs. 5.8%, p = 0.07). No significant differences were observed in the rates of death or stroke. Major bleeding was observed in 7.1% of the TNK-alone group and in 8.1% of the TNK-facilitated angioplasty group (p = 1.00).

CONCLUSIONS

In patients presenting with high-risk STEMI, TNK plus immediate angioplasty reduced the risk of recurrent ischemic events compared with TNK alone and was not associated with an increase in major bleeding complications.

Early eptifibatide improves TIMI 3 patency before primary percutaneous coronary intervention for acute ST elevation myocardial infarction: results of the randomized integrilin in acute myocardial infarction (INTAMI) pilot trial

AIMS

Adjunctive therapy with glycoprotein IIb/IIIa inhibitors has been shown to reduce ischaemic complications and improve clinical outcome in patients with primary percutaneous coronary intervention (PCI) for acute ST elevation myocardial infarction. Little is known about the use of eptifibatide in this setting.

METHODS AND RESULTS

One hundred and two patients with ST elevation myocardial infarction <12 h scheduled for primary percutaneous intervention were randomly assigned to early eptifibatide given in the emergency room (early) or optional eptifibatide at the time of PCI (late or no). Primary endpoint was the patency of the infarct vessel before PCI. Patients in the early group received their first eptifibatide bolus, a mean of 45 min before angiography. TIMI 3 patency before PCI was observed in 34% in the early group and 10% in late or no group (P=0.01). The incidence of complete ST resolution 1 h after PCI was 61% in early group and 66% in the late or no group, respectively (P=n.s.). There were no significant differences in the rates of TIMI 3 flow after PCI, death, reinfarction, stroke, and major bleeding complications until day 30.

CONCLUSION

In this pilot trial, double bolus eptifibatide given in the emergency room improved TIMI 3 grade flow of the infarct-related coronary artery before PCI. These results should be confirmed in a larger trial and whether this advantage translates into an improvement in clinical outcome should be tested in a trial with primary clinical endpoints.

Early administration of abciximab in patients with acute myocardial infarction improves angiographic and clinical outcome after primary angioplasty

Adjunctive use of abciximab during percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) improves clinical outcome. This study addresses the outcome of patients with AMI treated with abciximab, initiated either before transport to a PCI center (early group) or immediately upon arrival at the catheterization laboratory (late group) for primary PCI. Of 446 consecutive patients with AMI, angiographic data and clinical complications were evaluated up to 6 months after primary PCI. Patients received abciximab before transport (early group; n = 138) or just before the intervention (late group; n = 308). Baseline data, including transport time (45 +/- 15 min; range, 15-60 min), were comparable in both groups. Early reperfusion was more prevalent in the early group (35% vs. late 19%; P < 0.001). Furthermore, a better final TIMI 3 flow was noted in the early group (91% vs. late 83%; P = 0.05). Although mortality reduction attributable to early abciximab treatment could not be demonstrated, major adverse cardiac events (MACE) occurred in 27% in the early group and 36% in the late group (P = 0.05). Revascularization rates were similar, but repeat acute coronary syndromes were less frequent in the early group (11% vs. late group 20%; P = 0.04). In multivariate analysis, cardiogenic shock, out-of-hospital cardiac arrest, and previously known coronary artery disease were independent predictors of higher MACE rate, whereas early reperfusion and final TIMI 3 flow reduced 6-month MACE rate. Abciximab pretreatment of patients with AMI for primary PCI results in better initial and final TIMI flow and tends to improve 6-month clinical outcome.

Facilitated percutaneous coronary intervention in acute myocardial infarction: attractive concept but difficult to prove!

Facilitated percutaneous coronary intervention (PCI) refers to a strategy of immediate PCI following the administration of pharmacological therapies in acute myocardial infarction. It has evolved primarily from the time delays (due to geography or logistics) in getting acute myocardial infarction patients to the catheterization laboratory and the associated irreversible loss of myocardial muscle that occurs as door-to-balloon time increases. Facilitated PCI provides an opportunity to start treating many of these patients before they reach the catheterization laboratory and provides an ability to open the infarct-related artery before PCI, which is associated with better outcomes for AMI patients. Pharmacological strategies before PCI include: thrombolytic therapy, glycoprotein IIb/IIIa inhibitor alone, or a combination of thrombolytic therapy plus glycoprotein IIb/IIIa inhibitor. Initial results of angiographic studies show better patency with the latter strategy but at the expense of higher bleeding event rates. Ongoing trials are evaluating different combinations of thrombolytic and glycoprotein IIb/IIIa inhibitor therapy.