Clinical efficacy and safety of intracoronary vs. intravenous abciximab administration in STEMI patients undergoing primary percutaneous coronary intervention: a meta-analysis of randomized trials

Adjunctive therapy with abciximab has been proven to reduce mortality and reinfarction in patients with ST-elevation myocardial infarction (STEMI) referred to invasive management. Standard abciximab regimen consists of an intravenous (IV) bolus followed by a 12-h IV infusion. Experimental studies and small clinical trials suggest the superiority of intracoronary (IC) injection of abciximab over the IV route. We aimed to perform a meta-analysis of randomized controlled trials to assess the clinical efficacy and safety of IC vs. IV abciximab administration in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). The primary endpoint was mortality, while recurrent myocardial infarction and target vessel revascularization (TVR) were selected as secondary endpoints. The safety endpoint was the risk of major bleeding complications. A total of six randomized trials were finally included in the meta-analysis, enrolling a total of 1246 patients. Compared to IV route, IC abciximab was associated with a significant reduction in mortality (odds ratio, OR [95% confidence interval (CI)]?=0.43 [0.20-0.94], p=0.03), and TVR (OR [95% CI]?=0.53 [0.29-0.99], p=0.05). No differences in terms of recurrent myocardial infarction (OR [95% CI]?=0.54 [0.23-1.28], p=0.17) or major bleeding complications (OR [95% CI]?=0.91 [0.46-1.79], p=0.79) were observed between the two strategies. The present meta-analysis showed that IC administration of abciximab is associated with significant benefits in mortality at short-term follow-up compared to IV abciximab administration, without any excess of major bleeding in STEMI patients undergoing PPCI. However, further trials are warranted to establish the optimal strategy of abciximab treatment in this setting.     

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

Background: Abciximab is beneficial in patients with ST‐segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). However, the optimal administration route of the initial bolus of abciximab, that is, intravenous (IV) versus intracoronary (IC), has been questioned. Preliminary studies suggest that IC‐bolus is superior, probably due to high local concentration. In this study, we assess the short‐term efficacy and safety of IC compared to IV bolus of abciximab in patients with STEMI during pPCI. Methods: In 2006–2008, we randomized 355 STEMI patients who underwent pPCI and had indication for abciximab to either IV or IC bolus followed by a 12‐hour IV infusion. Primary end‐points at 30 days were target vessel revascularization (TVR), recurrent myocardial infarction (MI) or death, and the composite of the three. Secondary end‐points were bleeding complications. Results: The two groups (IV n = 170;IC n = 185) were similar with respect to baseline characteristics. Mortality at 30 days was 5.3% in the IV group compared to only 1.1% in the IC group (P = 0.02). TVR was performed in 9.4% in the IV group compared to 3.8% in the IC group (P = 0.03). No significant difference in MI rates was seen (IV 4.7% vs. IC 2.7%; P = 0.32). We found a significant reduction in the composite end‐point (IV 19.4% vs. IC 7.6%; P = 0.001) in favor of IC use. Major bleeding complications were similar (IV 2.4% vs. IC 1.6%; P = 0.62). Neither difference was observed in minor bleedings (IV 14.1% vs. IC 9.7%; P = 0.20). Conclusion: IC administration of bolus abciximab in STEMI patients undergoing pPCI reduces 30‐day mortality and TVR and tends to reduce MI, compared to IV‐bolus. (J Interven Cardiol 2011;24:105–111)     

Benefits from intracoronary as compared to intravenous abciximab administration for STEMI patients undergoing primary angioplasty: a meta-analysis of 8 randomized trials

BackgroundAdjunctive abciximab administration has been demonstrated to reduce mortality and reinfarction in patients with ST-elevation myocardial infarction (STEMI) referred to invasive management. Standard abciximab regimen consists of an intravenous (IV) bolus followed by a 12-h IV infusion. Experimental studies and small clinical trials suggest the superiority of intracoronary (IC) injection of abciximab over IV route. Therefore, the aim of the current study was to perform a meta-analysis of randomized trials (RCTs) to assess the clinical efficacy and safety of IC vs IV abciximab administration in STEMI patients undergoing primary angioplasty.MethodsWe obtained results from all RCTs enrolling STEMI patients undergoing primary percutaneous coronary intervention (PCI). The primary endpoint was mortality, while recurrent myocardial infarction, postprocedural epicardial (TIMI 3) and myocardial (MBG 2–3) perfusion were identified as secondary endpoints. The safety endpoint was the risk of major bleeding complications.ResultsA total of 8 randomized trials were finally included in the meta-analysis, enrolling a total of 3259 patients. As compared to IV route, IC abciximab was associated with a significant improvement in myocardial perfusion (OR [95% CI] = 1.76 [1.28–2.42], p < 0.001), without significant benefits in terms of mortality (OR [95% CI] = 0.85 [0.59–1.23], p = 0.39), reinfarction (OR [95% CI] = 0.79 [0.46–1.33], p = 0.37), or major bleeding complications (OR [95% CI] = 1.19 [0.76–1.87], p = 0.44). However, we observed a significant relationship between patient's risk profile and mortality benefits from IC abciximab administration (p = 0.011).ConclusionsThe present updated meta-analysis showed that IC administration of abciximab is associated with significant benefits in myocardial perfusion, but not in clinical outcome at short-term follow-up as compared to IV abciximab administration, without any excess of major bleedings in STEMI patients undergoing primary PCI. However, a significant relationship was observed between patient's risk profile and mortality benefits from IC abciximab administration. Therefore, waiting for long-term follow-up results and additional randomized trials, IC abciximab administration cannot be routinely recommended, but may be considered in high-risk patients.     

Effects of early abciximab administration before primary percutaneous coronary intervention on left ventricular function assessed by cardiac magnetic resonance

BACKGROUND: It has been shown that early abciximab administration before primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI) improves efficacy of treatment. However, there are no data on the impact of this strategy on left ventricular (LV) function during long-term follow-up. AIM: To analyse the effects of early abciximab administration in patients with first anterior STEMI treated with pPCI on infarct size and LV function assessed by cardiac magnetic resonance. METHODS: A total of 59 patients with STEMI, <12 hours from the chest pain onset, without cardiogenic shock, admitted to local hospitals without interventional facilities, with anticipated delay to pPCI <90 min were randomly assigned to two study groups: 27 patients received abciximab before transfer to the catheterisation laboratory (early abciximab group), and 32 patients received abciximab in the catheterisation laboratory just before pPCI (late abciximab group). All patients received aspirin and heparin (70 U/kg) before transfer to the cath lab. Clopidogrel loading dose was administered in the cath lab before angiography. RESULTS: Cardiac magnetic resonance was performed in 14 patients from each study group 1 year after pPCI and revealed a significantly lower LV end-systolic volume index (p=0.003), end-diastolic volume index (p=0.009) and better ejection fraction (p <0.05) in patients who received abciximab early. CONCLUSIONS: Early abciximab administration prior to transfer for pPCI in patients with first anterior STEMI results in a lower degree of LV remodelling and better LV ejection fraction at 1-year follow-up compared to late abciximab administration in the cath lab during pPCI.     

Comparison of 600 versus 300-mg Clopidogrel loading dose in patients with ST-segment elevation myocardial infarction undergoing primary coronary angioplasty

The aim of the present study was to compare 600- and 300-mg clopidogrel loading doses in patients with ST-segment elevation myocardial infarctions who underwent primary percutaneous coronary intervention (PCI). Two hundred fifty-five consecutive patients presenting with ST-segment elevation myocardial infarctions who underwent primary PCI were enrolled. Patients were divided into 2 groups on the basis of the loading dose of clopidogrel received before the procedure (600 vs 300 mg). Procedural angiographic end points and 1-year major adverse cardiac events were compared between the 2 groups. Major adverse cardiac events were defined as death, nonfatal myocardial infarction, and target vessel revascularization. There were no significant differences in baseline clinical and angiographic features between the 2 groups: 157 (62%) in the clopidogrel 600 mg group and 98 (38%) in the 300 mg group. Patients receiving 600-mg loading dose of clopidogrel showed a significantly lower incidence of post-PCI myocardial blush grade 0 or 1 (odds ratio 0.64, 95% confidence interval 0.43 to 0.96, p = 0.03) and significantly less common no-reflow phenomenon (odds ratio 0.38, 95% confidence interval 0.15 to 0.98, p = 0.04) compared to those in the 300-mg group. Propensity-adjusted Cox analysis showed significantly higher survival free of major adverse cardiac events in patients receiving 600-mg loading dose of clopidogrel compared to those receiving the lower dose (hazard ratio 0.57, 95% confidence interval 0.33 to 0.98, p = 0.04). In conclusion, a 600-mg loading dose of clopidogrel is associated with improvements in procedural angiographic end points and 1-year clinical outcomes in patients with ST-segment elevation myocardial infarction who undergo primary PCI compared to a 300-mg dose.     

Meta-analysis of randomized controlled trials comparing intracoronary and intravenous administration of glycoprotein IIb/IIIa inhibitors in patients with ST-elevation myocardial infarction

Glycoprotein IIb/IIIa receptor inhibitors (GPIs) have been widely adopted as an adjuvant regimen during primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction, but whether intracoronary administration of these potent antiplatelet agents conveys better efficacy and safety over the intravenous route has not been well addressed. A meta-analysis was performed by a systematic search of the published research for randomized controlled trials comparing intracoronary versus intravenous administration of GPIs in patients with ST-segment elevation myocardial infarction. Eight studies involving 686 patients in the intracoronary arm and 660 in the intravenous arm met the inclusion criteria. Postprocedural Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.08 to 1.98, p <0.05) and myocardial reperfusion grade 2 or 3 (OR 1.78, 95% CI 1.29 to 2.46, p <0.001) were markedly more often achieved in patients who received intracoronary boluses of GPIs than those receiving the intravenous strategy. Intracoronary administration resulted in a reduced incidence of mortality (OR 0.44, 95% CI 0.21 to 0.92, p <0.05), target vessel revascularization (OR 0.53, 95% CI 0.29 to 0.99, p <0.05), and the composite end point of major adverse cardiac events (OR 0.48, 95% CI 0.31 to 0.76, p <0.005) at 30-day follow-up. No significant difference was found in terms of major or minor bleeding (OR 1.14, p = 0.71, and OR 0.86, p = 0.47 respectively). In conclusion, intracoronary administration of GPIs yielded favorable outcomes in postprocedural blood flow restoration and 30-day clinical prognosis in patients with ST-segment elevation myocardial infarction. The intracoronary use of GPIs can be recommended as a preferred regimen during primary percutaneous coronary intervention.     

Prognostic value of uric acid in patients with ST-elevated myocardial infarction undergoing primary coronary intervention

Elevated uric acid (UA) levels have been associated with cardiovascular disease in epidemiologic studies. The relation between UA levels and long-term outcomes in patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention is not known. Data from 2,249 consecutive patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention were evaluated. Patients were divided into 2 groups with high or low UA using upper limits of normal of 6 mg/dl for women and 7 mg/dl for men. There were 1,643 patients in the low-UA group (mean age 55.9 ± 11.6 years, 85% men) and 606 patients in the high-UA group (mean age 60.5 ± 12.6 years, 76% men). Serum UA levels were 8.0 ± 1.5 mg/dl in the high-UA group and 5.2 ± 1.0 mg/dl in the low-UA group (p <0.001). The in-hospital mortality rate was significantly higher in patients with high UA levels (9% vs 2%, p <0.001), as was the rate of adverse outcomes in patients with high UA. The mean follow-up time was 24.3 months. Cardiovascular mortality, reinfarction, target vessel revascularization, heart failure, and major adverse cardiac events were all significantly higher in the high-UA group. In a multivariate analyses, high plasma UA levels were an independent predictor of major adverse cardiac events in the hospital (odds ratio 2.03, 95% confidence interval 1.25 to 3.75, p = 0.006) and during long-term follow-up (odds ratio 1.64, 95% confidence interval 1.05 to 2.56, p = 0.03). In conclusion, high UA levels on admission are independently associated with in-hospital and long-term adverse outcomes in patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention.     

冠状动脉介入治疗中阿昔单抗两种给药途径治疗效果比较的meta分析

目的:比较冠状动脉介入治疗（PCI）中冠状动脉内和静脉内使用阿昔单抗的治疗效果。方法: 计算机检索 PubMed、 EMbase、 Cochrane图书馆、 中国生物医学文献光盘数据等数据库,系统性搜索已发表的相关临床研究,并对纳入的研究进行质量评价,对相关结果进行meta分析。共纳入6个随机对照临床研究,共1 138例患者,其中试验组580例（冠状动脉内运用阿昔单抗组）,对照组558 例（静脉内运用阿昔单抗组）。纳入患者均为急性ST段抬高型心肌梗死。结果: 冠状动脉内运用阿昔单抗组仅在心肌梗死溶栓后Ⅲ级血流所占比例优于静脉内运用阿昔单抗组［RR=1.06,95%CI（1.01,1.12）,P=0.02］。而在病死率［RR=0.48,95%CI（0.23,1.02）,P=0.06］、靶血管血运重建［RR=0.55,95%CI（0.30,0.99）,P=0.05］,以及出血事件发生率［RR=0.88,95%CI（0.63,1.23）,P=0.44］,两组没有统计学意义上的差异。结论:与静脉内使用阿昔单抗组相比,冠状动脉内使用阿昔单抗改善了急性ST段抬高型心肌梗死患者的心肌灌注,但并未降低其病死率、靶血管血运重建及出血事件发生率。     

Primary percutaneous coronary intervention compared with fibrinolysis for myocardial infarction in diabetes mellitus: results from the Primary Coronary Angioplasty vs Thrombolysis-2 trial

BACKGROUND: There is growing evidence for a clinical benefit of primary percutaneous coronary intervention (PCI) compared with fibrinolysis; however, whether the treatment effect is consistent among patients with diabetes mellitus is unclear. We compared PCI with fibrinolysis for treatment of ST-segment elevation myocardial infarction in patients with diabetes mellitus. METHODS: A pooled analysis of individual patient data from 19 trials comparing primary PCI with fibrinolysis for treatment of ST-segment elevation myocardial infarction was performed. Trials that enrolled at least 50 patients with ST-segment elevation myocardial infarction and randomized patients to receive either primary PCI or fibrinolysis were considered for inclusion in our study. Clinical end points were total deaths, recurrent infarction, death or nonfatal recurrent infarction, and stroke, measured 30 days after randomization. RESULTS: Of 6315 patients, 877 (14%) had diabetes. Thirty-day mortality (9.4% vs 5.9%; P < .001) was higher in patients with diabetes. Mortality was lower after primary PCI compared with fibrinolysis in both patients with diabetes (unadjusted odds ratio, 0.49; 95% confidence interval, 0.31-0.79; P = .004) and without diabetes (unadjusted odds ratio, 0.69; 95% confidence interval, 0.54-0.86, P = .001), with no evidence of heterogeneity of treatment effect (P = .24 for interaction). Recurrent infarction and stroke were also reduced after primary PCI in both patient groups. After multivariable analysis, primary PCI was associated with decreased 30-day mortality in patients with and without diabetes, with a point estimate of greater benefit in diabetic patients. CONCLUSIONS: Diabetic patients with ST-segment elevation myocardial infarction treated with reperfusion therapy have increased mortality compared with patients without diabetes. The beneficial effects of primary PCI compared with fibrinolysis in diabetic patients are consistent with effects in nondiabetic patients.     

System delay and timing of intervention in acute myocardial infarction (from the Danish Acute Myocardial Infarction-2 [DANAMI-2] trial)

The interval from the first alert of the healthcare system to the initiation of reperfusion therapy (system delay) is associated with mortality in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention (pPCI). The importance of system delay in patients treated with fibrinolysis versus pPCI has not been assessed. We obtained data on system delay from the Danish Acute Myocardial Infarction-2 study, which randomized 1,572 patients to fibrinolysis or pPCI. The study end points were 30-day and 8-year mortality. The short system delays were associated with reduced absolute mortality in both the fibrinolysis group (<1 hour, 5.6%; 1 to 2 hours, 6.9%; 2 to 3 hours, 9.5%; and >3 hours, 11.5%; test for trend, p = 0.08) and pPCI group (<1 hour, not assessed; 1 to 2 hours, 2.6%; 2 to 3 hours, 7.5%; >3 hours, 7.7%; test for trend, p = 0.02). The lowest 30-day mortality was obtained with pPCI and a system delay of 1 to 2 hours (vs fibrinolysis within <1 hour, adjusted hazard ratio 0.33; 95% confidence interval 0.10 to 1.10; p = 0.07; vs fibrinolysis within 1 to 2 hours, adjusted hazard ratio 0.37; 95% confidence interval 0.14 to 0.95; p = 0.04). pPCI and system delay >3 hours was associated with a similar 30-day and 8-year mortality as fibrinolysis within 1 to 2 hours. In conclusion, short system delays are associated with reduced mortality in patients with ST-segment elevation myocardial infarction treated with fibrinolysis as well as pPCI. pPCI performed with a system delay of <2 hours is associated with lower mortality than fibrinolysis performed with a faster or similar system delay.     

Relation between electrocardiographic ST-segment resolution and early and late outcomes after primary percutaneous coronary intervention for acute myocardial infarction

ST-segment resolution (STR) is a surrogate end point in reperfusion trials of acute myocardial infarction, but there are few data regarding the optimum methods of measurement, clinical predictors, and correlation with late cardiac mortality. Consecutive patients (n = 1,005) who had acute myocardial infarction and >/=2 mm ST-segment elevation controlled with primary percutaneous coronary intervention (PCI) constituted our study group. Follow-up was obtained in 97% of patients at a median of 6.2 years. STR measured as maximum ST-segment elevation after PCI provided better discrimination of late cardiac mortality than did STR measured as percent resolution. Complete STR (<1.0 mm ST-segment elevation after PCI) was achieved in only 42% of patients. Anterior infarction, Killip's class 3 to 4, and Thrombolysis In Myocardial Infarction flow grades <2 before PCI and <3 after PCI were strong independent predictors of partial or poor STR. STR (complete [<1.0 mm] vs partial [1.0 to 2.0 mm] vs poor [>2.0 mm]) correlated with in-hospital mortality (4.0% vs 6.7% vs 11.6%, p = 0.005), reinfarction (1.4% vs 3.4% vs 6.1%, p = 0.01), and late cardiac mortality (17% vs 25% vs 44%, p <0.0001). Correlation with late mortality was stronger for nonanterior than for anterior infarction. Poor STR was a strong independent predictor of late mortality (hazard ratio 1.63, 95% confidence interval 1.06 to 2.50, p = 0.028), even after adjusting for Thrombolysis In Myocardial Infarction flow. These data support the use of STR as a simple method to stratify patients by risk after primary PCI for acute myocardial infarction and support the use of STR as a surrogate end point in reperfusion trials of acute myocardial infarction.     

Analysis of reported randomized trials of streptokinase therapy for acute myocardial infarction in the 1980s

Trials of intracoronary (IC) and intravenous (IV) streptokinase (SK) therapy for myocardial infarction have shown variable effects on mortality and left ventricular (LV) function. A pooled analysis of 10 randomized trials involving a total of 14,355 patients was performed to look for overall trends in the change in mortality within 6 weeks (group A) and after 6 weeks (group B) of follow-up, and the change in LV function. All 10 trials, 7 with IC and 3 with IV SK, were randomized after 1980. There was a significant reduction in mortality risk in patients in group A treated with IV SK (pooled odds ratio = 0.81, 95% confidence interval = 0.73 to 0.90, p less than 0.001). In contrast, no significant differences in mortality were detected in patients in group B treated with IV SK or in patients in either group treated with IC SK. Two IV SK trials that prospectively stratified patient population according to duration of symptoms showed a greater reduction in mortality with administration of SK therapy within 3 hours of onset of symptoms. Analysis of LV function was performed before, within 96 hours after and 1 to 4 weeks after SK therapy. Only 2 of 7 IC SK trials showed significantly greater improvement in global LV ejection fraction in SK group compared with a control group, both showing improvement in LV function between early and late after treatment. Thus, IV SK therapy significantly reduces short-term risk of death after acute myocardial infarction; 2 trials show a greater reduction in mortality risk with earlier institution of IV SK therapy.     

Comparison of intracoronary vs. intravenous administration of abciximab in coronary stenting.

There have been animal and human studies looking at intracoronary (IC) use of abciximab with good short-term clinical outcomes. There exists no data comparing intracoronary with intravenous (IV) administration of abciximab beyond 30 days. We compared the clinical outcomes between the IC (n = 101) and IV (n = 72) group of patients. Patients who had coronary stenting and received abciximab were included in the study. All the patients received the standard systemic bolus dose of abciximab 0.25 mg/kg either via the IC or IV route, followed by a 12-hr IV infusion at 0.125 microg/kg/min. The 6-month composite endpoint of death or myocardial infarction was slightly higher in the IV (13.9%) than in the IC group (5.9%; P = 0.04). The frequency of bleeding complications was similar in both groups. The IC bolus route of abciximab may be superior to the intravenous route. Prospective randomized trials are warranted to validate these findings.     

Aborted myocardial infarction in intracoronary compared with standard intravenous abciximab administration in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction

Backgound

Abciximab reduces major adverse cardiac events (MACEs) in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Intracoronary (IC) abciximab bolus application might be more effective than a standard intravenous (IV) bolus. So far the occurrence of aborted MI, a new therapeutic target of effective treatment in STEMI, has not been evaluated in IC versus IV abciximab administration in STEMI patients undergoing primary PCI.

Methods

To investigate the extent of aborted MI, 154 patients undergoing primary PCI were randomized to either IC (n = 77) or IV (n = 77) bolus abciximab administration with subsequent 12-hour intravenous infusion. For assessment of infarct size and extent of microvascular obstruction, all patients underwent late enhancement magnetic resonance imaging (MRI). Aborted MI was defined by major (≥ 50%) ST-segment resolution and a lack of subsequent cardiac enzyme rise ≥ 2 the upper normal limit. We also assessed the occurrence of true aborted MI defined as the absence of myocardial necrosis in MRI.

Results

The incidence of aborted MI was significantly higher in the IC group (p = 0.04); true aborted MI was only observed in the IC abciximab group (p = 0.01). At multivariable logistic regression analysis, IC abciximab application was a significant independent predictor of true aborted MI (p = 0.03). Aborted MI patients had an excellent prognosis at 6-month follow-up with no MACE as compared to 24 events in patients with non-aborted MI.

Conclusions

IC bolus application of abciximab in STEMI patients undergoing primary PCI results in a higher incidence of aborted MI and subsequent improved clinical outcome.     

ST-segment resolution 60 minutes after combination treatment of abciximab with reteplase or reteplase alone for acute myocardial infarction (30-day mortality results from the resolution of ST-segment after reperfusion therapy substudy)

The combination of abciximab with thrombolytic therapy when treating acute ST-elevation myocardial infarction has been hypothesized to enhance microvascular perfusion. Resolution of ST-segment elevation after thrombolytic therapy is believed to be a marker of myocardial reperfusion and to predict mortality rate. Among 16,588 patients enrolled in the Fifth Global Use of Strategies to Open Occluded Arteries in Acute Myocardial Infarction trial, 1,764 consecutive patients from selected centers had their study electrocardiograms evaluated by a core laboratory for ST-segment deviation resolution 60 minutes after treatment. Patients were categorized into 4 groups: complete resolution (>70%), partial resolution (<70% to 30%), no resolution (<30%), and worsening ST-segment deviation. Patients treated with reteplase or a combination of reteplase plus abciximab had similar rates of complete resolution (32% vs 34%), partial resolution (29% vs 27%), no resolution (15% vs 16%), and worsening ST-segment elevation (23 vs 23%; p = 0.59). The 30-day mortality rates in these 4 groups were 2.1%, 5.2%, 5.5%, and 8.1% (p <0.001). Even after accounting for baseline variables, incomplete ST-segment resolution (<70%) was associated with an increased risk of death within 30 days (adjusted hazard ratio 2.41, 95% confidence interval 1.25 to 4.63, p <0.008). Thus, ST-segment resolution at 60 minutes was no different in patients treated with full-dose reteplase from those treated with a combination of abciximab and reteplase. Patients with >70% ST-segment resolution within 60 minutes had markedly decreased mortality rates, irrespective of treatment.     

Combined prognostic utility of ST segment in lead aVR and troponin T on admission in non-ST-segment elevation acute coronary syndromes

Many studies have shown that ST-segment depression is a strong predictor of poor outcomes in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACSs); however, lead aVR was not considered in these studies. The present study examined the prognostic usefulness of the 12-lead electrocardiogram in combination with biochemical markers in 333 patients with NSTE-ACS. ST-segment deviation of > or =0.5 mm was considered clinically significant. Coronary angiography was performed a median of 3 days after admission in all patients. The primary end point was the composite of death, myocardial infarction, and urgent revascularization at 90 days. ST-segment elevation in lead aVR (odds ratio 13.8, 95% confidence interval 1.43 to 100.9, p = 0.03) and increased troponin T (odds ratio 7.9, 95% confidence interval 1.22 to 123.8, p = 0.04) were the only independent predictors of restricted events (death or myocardial infarction) at 90 days. ST-segment elevation in lead aVR (odds ratio 12.8, 95% confidence interval 4.80 to 33.9, p < 0.0001) and increased troponin T (odds ratio 2.03, 95% confidence interval 1.20 to 4.29, p = 0.04) were also the only independent predictors of adverse events (death, myocardial infarction, or urgent revascularization) at 90 days. When ST-segment status in lead aVR was combined with troponin T, patients with ST-segment elevation in lead aVR and increased troponin T had the highest rates of left main or 3-vessel coronary disease (62%) and 90-day adverse outcomes (47%). In conclusion, our findings suggest that ST-segment status in lead aVR combined with troponin T on admission is a simple and useful clinical tool for early risk stratification in patients with NSTE-ACS.     

Comparison between glycoprotein IIb/IIIa blockade and distal protection device for the restoration of myocardial perfusion during percutaneous coronary intervention for acute myocardial infarction

We compared the use of abciximab with a distal balloon occlusion device in preserving myocardial perfusion among patients undergoing acute percutaneous coronary intervention for ST-segment elevation myocardial infarction. Of 114 patients, 40 were treated with abciximab and 74 with distal protection. Although pre-treatment with abciximab resulted in marginally better myocardial perfusion at initial coronary angiography, distal protection emerged superior at the end of the procedure. The use of distal protection was associated with an adjusted odds of 4 (p = 0.017) for achieving normal myocardial perfusion and adjusted reduction of 11 corrected TIMI frame counts (p = 0.001) compared with abciximab.     

Impact of congestive heart failure in patients with non-ST-segment elevation acute coronary syndromes

The presence of congestive heart failure (CHF) has been associated with treatment disparities and worse outcomes in patients with ST-segment elevation myocardial infarction, but the incidence and effect of CHF in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACSs) has not been well characterized. We evaluated 45,744 patients with NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes) who were treated at 424 hospitals in the CRUSADE Quality Improvement Initiative between March 2000 and March 2003. Treatment patterns and in-hospital outcomes in patients with signs of CHF on presentation and those who developed in-hospital CHF were compared with those in patients without CHF. In total, 10,398 patients (22.7%) had signs of CHF on presentation, and 1,664 patients (3.6%) later developed in-hospital CHF. Compared with patients without CHF, early (<24 hours from presentation) medications and invasive cardiac procedures were used less often in patients with signs of CHF on presentation. Likewise, patients with in-hospital CHF were less likely than those without CHF to receive acute antiplatelet agents and undergo cardiac catheterization but more likely to receive acute beta blockers, angiotensin-converting enzyme inhibitors, and heparin and to undergo coronary artery bypass grafting. Adjusted mortality was higher in patients with signs of CHF on presentation (odds ratio 2.64, 95% confidence interval 2.31 to 3.01) and those with in-hospital CHF (odds ratio 4.93, 95% confidence interval 4.05 to 5.99) than in patients without CHF. In conclusion, CHF occurs frequently in patients with NSTE ACS but is associated with less aggressive treatment and a higher risk of mortality. Further study is needed to determine the causes of these treatment differences and the optimal therapeutic approach for patients with NSTE ACS and concomitant CHF.     

Use of abciximab prior to primary angioplasty in STEMI results in early recanalization of the infarct-related artery and improved myocardial tissue reperfusion - results of the Austrian multi-centre randomized ReoPro-BRIDGING Study.

AIMS: The aim of the ReoPro-BRIDGING Austrian multi-centre study was to investigate the effects of abciximab (ReoPro) on early reperfusion in ST-elevation myocardial infarction prior to or during primary percutaneous coronary angioplasty (pPCI). METHODS AND RESULTS: Fifty-five patients with STEMI were randomized either to start abciximab (0.25 mg/kg bolus followed by 10 microg/min infusion) during the organization phase for pPCI (Group 1, n=28) or immediately before pPCI (Group 2, n=27). The time between first bolus of abciximab and first balloon inflation of pPCI was 83+/-18 vs 21+/-13 min in Group 1 vs 2. The pre-pPCI ST-segment resolution (55+/-21.4% vs 42.4+/-18.2%, p=0.005), TIMI flow grade 3 (29% vs 7%, p=0.042), corrected TIMI frame count (58.4+/-32.7 vs 78.9+/-28.4 frame, p=0.018) %diameter stenosis (76.3 /63.5-100/ vs 100 /73.5-100/; median /interquartile range/, p=0.023), were significantly higher in Group 1 vs Group 2. Quantitative myocardial dye intensity measurement revealed a significantly higher grade of myocardial tissue perfusion (1 /0-9.25/ vs 0 /0-3.0/ grey pixel unit, p=0.048) in Group 1 before pPCI. Rapid release of cardiac enzymes was observed in Group 1 as compared with Group 2: rate of rise of CK was 210+/-209 vs 97+/-95 U/l/h (p=0.015). QRS score indicated a smaller infarct size in Group 1 (4.8+/-3.8 vs 7.6+/-3.5, p=0.011) on day 7. CONCLUSION: The use of abciximab in the organization phase for pPCI results in signs of early recanalization of the infarct-related artery and a subsequent improved myocardial tissue reperfusion.