Prehospital Abciximab in ST-Segment Elevation Myocardial Infarction Results of the Randomized, Double-Blind MISTRAL Study
Pôle d'Activité Médico-Chirurgicale Cardiovasculaire and SAMU 67, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France. Circulation Cardiovascular Interventions
(Impact Factor: 6.22).
02/2012; 5(1):69-76, S1. DOI: 10.1161/CIRCINTERVENTIONS.111.961425
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.
Available from: Artur Dziewierz
- "No interaction between gender and effects of upstream GPIIb–IIIa inhibitors administration on mortality was confirmed. In the recently published MISTRAL study, despite enhancement of early reperfusion before PCI, and reduction of the risk of angiographic complications of PCI no mortality benefit was confirmed for in the ambulance versus in the cathlab use of abciximab . Importantly, the MISTRAL study included rather small and highly selected population with a low-risk profile (Killip class >I in 8 % of patients, diabetes mellitus in 8 %, and overall mortality 1.17 %). "
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ABSTRACT: The present study assessed the impact of early administration of abciximab in female and male patients with ST-segment elevation myocardial infarction (STEMI) transferred for primary angioplasty (PPCI). Data were gathered for 1,650 consecutive patients with STEMI transferred for PPCI from hospital networks in seven countries in Europe from November 2005 to January 2007 (the EUROTRANSFER Registry population). Among 1,086 patients who received abciximab, there were 186 women and 541 men who received abciximab early (>30 min before PPCI), and 86 women and 273 men treated with late abciximab. Female patients were high-risk individuals, with advanced age and increased rate of ischemic events. Early abciximab administration was associated with enhanced patency of the infarct-related artery before PPCI, and improved epicardial flow after PPCI in both women and men. Early abciximab in women led to the decrease in ischemic events, including 30 day (adjusted OR 0.26, 95 % CI 0.10-0.69, p = 0.007) and 1 year (adjusted OR 0.37, 95 % CI 0.16-0.84, p = 0.017) mortality reduction. In contrast, the reduction in 30 day (adjusted OR 0.69, 95 % CI 0.35-1.39, p = 0.27) and 1 year (adjusted OR 0.68, 95 % CI 0.38-1.22, p = 0.19) mortality was not significant in men. The frequency of bleeding events was similar in the early abciximab group compared to the late abciximab group in both women and men. Early administration of abciximab improved patency of the infarct-related artery before and after PPCI, and led to improved survival in female patients with STEMI.
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ABSTRACT: Diabetes is an important determinant of prognosis in patients with ST-segment elevation myocardial infarction (STEMI). Limited data are available concerning benefits and risks of upstream abciximab administration in diabetic patients. Thus, the objective of the study was to assess the impact of early abciximab administration before primary angioplasty (PCI) for STEMI in diabetic patients.
Data were gathered for 1650 consecutive STEMI patients transferred for primary PCI from hospital networks in seven countries in Europe from November 2005 to January 2007 (the EUROTRANSFER Registry population). Patients were stratified by diabetes mellitus presence and then by abciximab administration strategy (early - more than 30 min before PCI vs. late).
Diabetes mellitus was diagnosed in 262 (15.9%) patients. Patients with diabetes mellitus were high-risk individuals, with advanced age, higher prevalence of comorbidities and increased risk of ischemic events during follow-up in comparison to non-diabetic patients. A total of 1086 patients who received abciximab were identified. Strategy of early abciximab administration was associated with enhanced infarct-related artery patency before PCI, and improved epicardial flow after PCI in both diabetic and non-diabetic patients. Importantly, early abciximab in diabetic patients led to the decrease in ischemic events, including 30-day (OR 0.260, 95% CI 0.089-0.759, p = 0.012) and 1-year (OR 0.273, 95% CI 0.099-0.749, p = 0.012) mortality reduction. However, only a trend toward improved survival was confirmed after adjustment for potential confounders. On the contrary, the reduction of 30-day (OR 0.620, 95% CI 0.334-1.189, p = 0.16) and 1-year (OR 0.643, 95% CI 0.379-1.089, p = 0.10) mortality rates was not significant among non-diabetic patients.
Early administration of abciximab improves infarct-related artery patency before and after primary PCI, and leads to improved survival in diabetic STEMI patients.
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