Intracoronary versus intravenous glycoprotein IIb/IIIa inhibitors during primary percutaneous coronary intervention in patients with STEMI: a systematic review and meta-analysis

BACKGROUND

Intracoronary (IC) administration of glycoprotein IIb/IIIa inhibitors (GPIs) has been studied as an adjunctive therapy to improve outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention. In this systematic review and meta-analysis, we aimed to evaluate the efficacy and safety of IC administration of GPIs compared with those of intravenous (IV) administration in patients with STEMI.

METHODS

We searched the MEDLINE, Embase, and Cochrane CENTRAL databases for relevant studies published before September 21, 2022. In total, 22 randomized controlled trials involving 7,699 patients were included.

RESULTS

The proportions of patients achieving thrombolysis in myocardial infarction grade 3 flow, myocardial blush grade 2/3, and complete ST-segment resolution were significantly higher in the IC group than in the IV group. Major adverse cardiac events (MACE) (RR: 0.54, 95% CI: 0.37-0.80) and heart failure (RR: 0.48, 95% CI: 0.25-0.91) within 1 month were significantly lower in the IC group than in the IV group; however, after 6 months, no difference was observed in MACE risk. Additionally, the risks of death and bleeding did not differ between the two routes of administration.

CONCLUSIONS

When considering adjunctive GPI administration for patients with STEMI, the IC route may offer greater benefits than the IV route in terms of myocardial reperfusion and reduced occurrence of MACE and heart failure within 1 month. Nonetheless, when making decisions for IC administration of GPIs, the absence of a benefit for bleeding risk and difficulty accessing the administration route should be considered.

Meta-Analysis of Randomized Trials of Intracoronary Versus Intravenous Glycoprotein IIb/IIIa Inhibitors in Patients With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

The efficacy and safety of glycoprotein IIb/IIIa inhibitors via intracoronary (IC) route versus the intravenous (IV) route are not well known. We conducted this meta-analysis of randomized trials evaluating the role of IC versus IV glycoprotein IIb/IIIa in patients undergoing primary percutaneous coronary intervention. The analysis included 14 trials with a total of 3,754 patients. The primary outcome of major adverse cardiac events (MACE) had no statistically significant difference between the IC and the IV groups (relative risk [RR] 0.74, 95% confidence interval [CI] 0.51 to 1.10). Subgroup analysis showed that short-term MACE (i.e., ≤3 months) was reduced in the IC compared with the IV group; however, long-term MACE (>3 months) was not. IC group was superior in achievement of post-procedural Thrombolysis In Myocardial Infarction 3 flow (RR 1.06, 95% CI 1.01 to 1.11), myocardial blush grade II to III (RR 1.15, 95% CI 1.08 to 1.23), ST-segment resolution rates (RR 1.15, 95% CI 1.03 to 1.29; p = 0.01), and improvement of left ventricular ejection fraction (standardized mean difference = 4.32, 95% CI 0.91 to 7.74). There was a trend for lower stent thrombosis with IC route (RR 0.50, 95% CI 0.24 to 1.03). There was no significant difference between the 2 groups in all-cause mortality, re-infarction, and major bleeding. In conclusion, despite lack of significant difference in overall MACE outcome, IC glycoprotein IIb/IIIa inhibitors may improve short -term MACE, Thrombolysis In Myocardial Infarction 3 flow, myocardial blush grade II- to III rates, ST-segment resolution, and left ventricular ejection fraction compared with the IV route.

Intracoronary versus intravenous administration of abciximab in patients with acute coronary syndrome: a meta-analysis

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.