Prehospital abciximab in ST-segment elevation myocardial infarction: results of the randomized, double-blind MISTRAL study.
ABSTRACT The value of prehospital initiation of glycoprotein IIb/IIIa inhibitors remains a controversial issue. We sought to investigate whether in-ambulance initiation of abciximab in patients with ST-segment elevation myocardial infarction (STEMI) improves ST-segment elevation resolution (STR) after primary percutaneous coronary intervention (PCI).
MISTRAL (Myocardial Infarction with ST-elevation Treated by Primary Percutaneous Intervention Facilitated by Early Reopro Administration in Alsace) is a prospective, randomized, double-blind study. Two hundred and fifty-six patients with acute STEMI were allocated to receive abciximab either in the ambulance (ambulance group, n=127) or in the catheterization laboratory (hospital group, n=129). The primary end point was complete (>70%) STR after PCI. Complete STR was not significantly different between the 2 groups (before PCI, 21.6% versus 15.5%, P=0.28; after PCI, 70.3% versus 65.8%, P=0.49). Thrombolysis In Myocardial Infarction (TIMI) 2 to 3 flow rates before PCI tended to be higher in the ambulance group (46.8% versus 35%, P=0.08) but not after PCI (70.3% versus 65.8%, P=0.49). Slow flow tended to be lower (5.6% versus 13.4%, P=0.07), and distal embolization occurred significantly less often in the ambulance group (8.1% versus 21.1%, P=0.008). One- and 6-month major adverse cardiac event rates were low and similar in both groups.
Early ambulance administration of abciximab in STEMI did not improve either STR or TIMI flow rate after PCI. However, it tended to improve TIMI flow pre-PCI and decreased distal embolization during procedure. Larger studies are needed to confirm these results.
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ABSTRACT: Introduction of antiplatelet agents has contributed substantially to improve the outcome of patients with acute coronary syndromes. Meta-analysis of the studies on abciximab administration during primary percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction (STEMI) has clearly confirmed the mortality benefit associated with intravenous bolus and infusion of abciximab compared to placebo. Recently, introduction of new oral P2Y12 inhibitors (prasugrel, ticagrelor), with a faster and more pronounced antiplatelet effect, have decreased the use of abciximab even in patients with STEMI. However, recent studies have shown a delayed onset of antiplatelet effect of new oral antiplatelet drugs in the setting of STEMI, especially in patients with hemodynamic compromise. Thus, the use of abciximab as an intravenous agent should be strongly considered when oral P2Y12 inhibitors might fail or cannot be given before primary PCI for STEMI. An additional benefit of abciximab administration was reported when abciximab was given early, before primary PCI, compared to typical periprocedural use. To the contrary, no clear clinical benefit was confirmed for intracoronary administration of abciximab compared with intravenous administration. Future studies should focus on the role of abciximab given on top of new oral P2Y12 inhibitor (prasugrel, ticagrelor) or used as an alternative to an intravenous P2Y12 inhibitor (cangrelor). Undoubtedly, the results of these studies will change everyday practice of STEMI treatment.Therapeutics and Clinical Risk Management 01/2014; 10:567-76. · 1.34 Impact Factor
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ABSTRACT: Although a fibrinolytic pharmacoinvasive strategy is recommended for STEMI patients unable to undergo timely primary PCI, there is limited data addressing outcomes specific to those with successful or unsuccessful pharmacologic reperfusion. Accordingly, we evaluated a contemporary pharmacoinvasive strategy for failed reperfusion and successful reperfusion within the STrategic Reperfusion Early After Myocardial infarction (STREAM) study. Among 1823 per-protocol-treated STEMI patients, we examined clinical outcomes, angiographic and electrocardiogram metrics in 3 groups; fibrinolysis requiring rescue (Rescue, n=348), fibrinolysis with scheduled angiography (Scheduled, n=516), and primary PCI (n=927). Compared to pharmacoinvasive patients undergoing scheduled angiography, rescue-patients were more likely to have anterior wall MI, more baseline ST-segment elevation and deviation as well as Q-waves in the distribution of their ST elevation. Residual ST-elevation ≥2mm 30 minutes post angiography occurred in 27.9%, 7.9%, and 24.8% of rescue, scheduled and primary PCI, respectively. Thirty-day composite event rates (all-cause death, cardiogenic shock, heart failure and re-infarction) were: rescue 18.7%, scheduled 5.5%, and primary PCI 13.9%; all-cause death: 6.1%, 2.1%, and 3.9%; cardiogenic shock: 7.5%, 2.0%, and 5.4%; heart failure: 11.8%, 2.3%, and 7.6% and re-infarction: 1.5%, 1.4%, and 2.2%, respectively. Compared to successfully reperfused patients undergoing scheduled angiography, the adjusted relative risk (RR) of the primary outcome was 2.92 (95% confidence interval (CI) (1.92–4.45)) in rescue patients. In conclusion, pharmacoinvasive treated patients requiring rescue angiography had higher baseline risk with more co-morbidities and worse 30-day outcomes compared to successful fibrinolytic-treated patients. Residual ST-elevation after reperfusion assists in defining prognosis.The American Journal of Cardiology 09/2014; · 3.21 Impact Factor
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ABSTRACT: Anti-thrombotic drugs constitute the cornerstone of therapy in the management of acute coronary syndromes (ACS) and for patients undergoing percutaneous coronary intervention. Anti-thrombotic therapy during percutaneous coronary intervention for ACS has evolved substantially over the past 15 years. In the original 1996 ACC/AHA guidelines for the management of acute myocardial infarction (MI), only one antiplatelet agent (aspirin) and one anticoagulant (unfractionated heparin) were recommended as class I therapies. Much has since changed and the contemporary therapeutic armoury for the treatment of ACS reflects the pharmacological advances that have taken place. Recent developments in the medical management of ACS have been based around developing drugs with more predictable efficacy and at known drug targets. However there has also been considerable development of novel agents. New pharmacotherapies for ACS reflect efforts to improve efficacy and minimize complications by increasing target specificity and reducing inter-individual variation in therapeutic response.Expert Review of Clinical Pharmacology 05/2014;