Intracoronary Versus Intravenous Administration of Abciximab in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention With Thrombus Aspiration The Comparison of Intracoronary Versus Intravenous Abciximab Administration During Emergency Reperfusion of ST-Segment Elevation Myocardial Infarction (CICERO) Trial

Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30001 9700 RB Groningen, Netherlands.
Circulation (Impact Factor: 14.95). 12/2010; 122(25):2709-17. DOI: 10.1161/CIRCULATIONAHA.110.002741
Source: PubMed

ABSTRACT administration of the glycoprotein IIb/IIIa inhibitor abciximab is an effective adjunctive treatment strategy during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Although small-scale studies have suggested beneficial effects of intracoronary over intravenous administration of abciximab, this has not been investigated in a medium-scale randomized clinical trial.
a total of 534 ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention with thrombus aspiration within 12 hours of symptom onset were randomized to either an intracoronary or an intravenous bolus of abciximab (0.25 mg/kg). Patients were pretreated with aspirin, heparin, and clopidogrel. The primary end point was the incidence of restored myocardial reperfusion, defined as complete ST-segment resolution. Secondary end points included myocardial reperfusion as assessed by myocardial blush grade, enzymatic infarct size, and major adverse cardiac events at 30 days. The incidence of complete ST-segment resolution was similar in the intracoronary and intravenous groups (64% versus 62%; P=0.562). However, the incidence of myocardial blush grade 2/3 was higher in the intracoronary group than in the intravenous group (76% versus 67%; P=0.022). Furthermore, enzymatic infarct size was smaller in the intracoronary than in the intravenous group (P=0.008). The incidence of major adverse cardiac events was similar in both groups (5.5% versus 6.1%; P=0.786).
in ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention with thrombus aspiration, intracoronary administration of abciximab compared with intravenous administration does not improve myocardial reperfusion as assessed by ST-segment resolution. However, intracoronary administration is associated with improved myocardial reperfusion as assessed by myocardial blush grade and a smaller enzymatic infarct size.

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    • "More recently, intracoronary delivery of GPI into the infarct related artery has been proposed to achieve further clinical efficacy, with the hypothesis that a higher local concentration can be reached through direct intracoronary bolus injection as compared to standard intravenous administration [4]. Clinical trials comparing intracoronary (IC) with intravenous (IV) abciximab bolus have shown conflicting results, with some studies being underpowered to evaluate clinical hard endpoints [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15]. Recently, the AIDA STEMI trial randomized a large number of patients to either intracoronary or intravenous administration of abciximab bolus, but failed to demonstrate a significant difference in the combined clinical endpoint [5]. "
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    ABSTRACT: BACKGROUND: Successful reperfusion of epicardial coronary arteries does not necessarily result in actual myocardial perfusion. Local intracoronary (IC) delivery of GP IIb/IIIa inhibitors (GPI) has been proposed to achieve further clinical efficacy when compared to standard intravenous (IV) administration. However clinical trials have shown conflicting results. The aim of the present study was to compare IC with IV abciximab administration on mortality and MACEs in patients with ACS undergoing PCI. METHODS: We performed a meta-analysis of all available clinical trials comparing intracoronary versus intravenous abciximab administration. RESULTS: At short-term analysis, incidence of MACEs was significantly lower in the IC group than in the IV group (OR=0.56; 95% CI 0.35-0.89; p=0.015). Interestingly, subgroup analysis showed that most benefit was coming from those studies with a main baseline LVEF<50% (OR=0.33 95% CI 0.18-0.59). Similarly, long-term incidence of MACEs was significantly lower in the IC group than in the IV group (OR=0.47; 95% CI 0.31-0.71; p<0.001), with most benefit coming from those studies enrolling patients with a main baseline EF<50% (OR=0.38 95% CI 0.23-0.63 p<0.001). In addition, long-term incidence of death was also lower in the IC group than in the IV group (OR=0.42; 95% CI 0.20-0.86; p=0.009). CONCLUSIONS: Our meta-analysis provides evidence of a net clinical benefit for intracoronary versus intravenous abciximab administration, with the highest benefit observed in high-risk ACS patients, such as those with reduced baseline LVEF.
    International journal of cardiology 12/2012; 168(2). DOI:10.1016/j.ijcard.2012.12.003 · 6.18 Impact Factor
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    • "However, the incidence of myocardial blush grade 2/3 was significantly higher (76% vs 67%; p = 0.022) and the size of enzymatic infarct significantly lower (5.5 vs 6.1%; p = 0.008) in the intracoronary group than the systemic group, indicating an improvement in myocardial reperfusion with the intracoronary administration of abciximab. The incidence of MACE was not different between the two groups [12]. However, recent data from the AIDA STEMI trial showed no benefit of intracoronary application of abciximab over intravenous administration for ST-segment resolution, or for the composite end point of death, reinfarction or new heart failure at 90 days [13]. "
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    ABSTRACT: Drug-eluting stents are the default treatment for acute coronary syndromes, unless concerns or contraindications preclude dual antiplatelet therapy (DAPT). Platelet microemboli and mediators from activated platelets can undermine the restoration of perfusion. Therefore, ST-segment elevation MI (STEMI) patients should receive antiplatelet treatments regardless of reperfusion strategy. This review offers an evidence-based comparison of the P2Y(12) antagonists that have been evaluated in STEMI. While several studies support clopidogrel in STEMI, the benefits emerge several hours after administration and vary considerably reflecting genetic, cellular and clinical inter-individual differences. Although higher clopidogrel loading doses may improve outcomes, ticagrelor and prasugrel are more potent, produce less inter-individual variability, and show a faster onset of action. Ticagrelor and prasugrel improve outcomes compared to clopidogrel, with manageable bleeding risks, although further studies with a longer follow up are needed. Studies directly comparing ticagrelor and prasugrel are now needed. In the meantime, most current guidelines focus on clopidogrel and, therefore, need revision. While several polymorphisms influence platelet activity, CYP2C19 variants are the most consistently linked to clopidogrel responsiveness. Consensus groups should consider the studies needed to allow routine pharmacogenomic testing. The evidence-based use of P2Y(12) antagonists in DAPT should further reduce the morbidity and mortality associated with STEMI.
    International journal of cardiology 06/2012; 166(2). DOI:10.1016/j.ijcard.2012.04.160 · 6.18 Impact Factor
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    ABSTRACT: INTRODUCTION: Anticoagulation is an integral part of both fibrinolytic therapy and percutaneous intervention (PCI) in the reperfusion treatment of ST-segment elevation AMI (STEMI). AREAS COVERED: This article reviews the choices of adjunctive anticoagulation regimens. Readers will appreciate the complexities of anticoagulation and the variable risk of clotting with ischemic/thrombotic complications versus that of bleeding. Antiplatelet therapy with aspirin and clopidogrel is recommended with fibrinolysis and PCI. Newer P2Y(12) inhibitors such as prasugrel and ticagrelor have been shown to reduce cardiovascular death, myocardial infarction (MI), stroke and stent thrombosis, as compared with clopidogrel. Ticagrelor has also been shown to reduce mortality. Glycoprotein IIb/IIIa inhibitors, by blocking the final pathway of platelet clumping with each other through bridging with fibrinogen, have the ability to disaggregate platelets, hence the potential for reducing thrombotic complications as well as increasing bleeding in patients undergoing PCI bleeding risks. Enoxaparin reduces death and MI compared with unfractionated heparin (UFH) with fibrinolytic therapy. There was a trend for a reduction in death, MI procedural failure or non-coronary artery bypass grafting (CABG) major bleeding compared with UFH in primary PCI. In primary PCI, bivalirudin has the advantage over UFH of inhibiting clot bound thrombin and reduces bleeding and mortality compared with the use of UFH plus glycoprotein IIb/IIIa inhibitors. Combinations of P2Y(12) antagonists and bivalirudin need to be tested to optimize the balance between efficacy and bleeding. EXPERT OPINION: This field is rapidly evolving with multiple appropriate approaches.
    Expert Opinion on Pharmacotherapy 02/2011; 12(2):213-23. DOI:10.1517/14656566.2010.518613 · 3.09 Impact Factor
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