Reduction of major adverse cardiac events with intracoronary compared with intravenous bolus application of abciximab in patients with acute myocardial infarction or unstable angina undergoing coronary angioplasty

Antiplatelet Agents in Acute ST Elevation Myocardial Infarction

Platelet aggregation and thrombus formation represent the basic mechanism for clinical, electrocardiographic, and biomarker changes consistent with acute coronary syndrome. Various oral and intravenous formulations of platelet function inhibitors have been developed to help decrease platelet aggregation due to acute atherosclerotic plaque rupture. In this article, we review the various mechanisms, pharmacokinetics/pharmacodynamics, and the key clinical trials related to the platelet inhibitors that form the basis for current recommendations of their use in the ST elevation myocardial infarction guidelines by the American College of Cardiology/American Heart Association.

Intracoronary pharmacological therapy versus aspiration thrombectomy in STEMI (IPAT-STEMI): A systematic review and meta-analysis of randomized trials

BACKGROUND

Thrombus load in STEMI patients remains a challenge in practice. It aggravates coronary obstruction leading to impaired myocardial perfusion, worsened cardiac function, and adverse clinical outcomes. Various strategies have been advocated to reduce thrombus burden.

OBJECTIVES

This meta-analysis aimed to evaluate the effectiveness of intracoronary-administered thrombolytics or glycoprotein IIb/IIIa inhibitors (GPI) in comparison with aspiration thrombectomy (AT) as an adjunct to percutaneous coronary intervention (PCI) among patients presenting with ST-segment elevation myocardial infarction (STEMI).

METHODS

A comprehensive literature search for randomized trials that compared intracoronary-administered thrombolytics or GPI with AT in STEMI patients who underwent PCI, was conducted using various databases (e.g., MEDLINE, EMBASE, CENTRALE). Primary outcome was procedural measures (e.g., TIMI flow grade 3, TIMI myocardial perfusion grade (TMPG) 3, Myocardial blush grade (MBG) 2/3, ST-segment resolution (STR)).

RESULTS

Twelve randomized trials enrolled 1,466 patients: 696 were randomized to intracoronary-administered pharmacological interventions and 553 to AT. Patients randomized to PCI alone were excluded. Thrombolytics significantly improved TIMI flow grade 3 (odds ratio = 3.71, 95% CI: 1.85-7.45), complete STR (odds ratio = 3.64, 95% CI: 1.60-8.26), and TMPG 3 (odds ratio = 5.31, 95% CI: 2.48-11.36). Thrombolytics significantly reduced major adverse cardiovascular events (MACE) (odds ratio = 0.29, 95% CI: 0.13-0.65) without increasing bleeding risk. Trial sequential analysis assessment confirmed the superiority of thrombolytics for the primary outcome. Intracoronary GPI, either alone or combined with AT, did not improve procedural or clinical outcomes.

CONCLUSIONS

Compared with AT, intracoronary-administered thrombolytics significantly improved myocardial perfusion and MACE in STEMI patients.

Morphine and myocardial ischaemia-reperfusion

Coronary heart disease (CHD) is a cardiovascular disease with high mortality and disability worldwide. The main pathological manifestation of CHD is myocardial injury due to ischaemia-reperfusion, resulting in the death of cardiomyocytes (apoptosis and necrosis) and the occurrence of cardiac failure. Morphine is a nonselective opioid receptor agonist that has been commonly used for analgesia and to treat ischaemic heart disease. The present review focused on morphine-induced protection in an animal model of myocardial ischaemia-reperfusion and chronic heart failure and the effects of morphine on ST segment elevation myocardial infarction (STEMI) patients who underwent pre-primary percutaneous coronary intervention (pre-PPCI) or PPCI. The signalling pathways involved are also briefly described.

Periprocedural Myocardial Infarction in Contemporary Practice

"Periprocedural myocardial infarction (MI) occurs infrequently in the current era of percutaneous coronary interventions (PCI) and is associated with an increased risk of mortality and morbidity. Periprocedural MI can occur due to acute side branch occlusion, distal embolization, slow flow or no reflow phenomenon, abrupt vessel closure, and nonidentifiable mechanical processes. Therapeutic strategies to reduce the risk of periprocedural MI include dual antiplatelet therapy, intravenous cangrelor in the periprocedural setting, intravenous glycoprotein IIb/IIIa inhibitor in high-risk patients, anticoagulation with unfractionated heparin, low-molecular-weight heparin or bivalirudin, and embolic protection devices during saphenous vein graft interventions."

Cardioprotective Effects of Intracoronary Morphine in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention: A Prospective, Randomized Trial

Background

A cardioprotective role of morphine acting via opioid receptors has been demonstrated, and previous preclinical studies have reported that morphine could reduce reperfusion injury and myocardial infarct size in a way similar to that of ischemic periconditioning. This study aimed to evaluate the effect of intracoronary morphine on myocardial infarct size in patients with ST‐elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Methods and Results

This study was designed as a 2‐center, prospective, randomized, open‐label, blinded end point trial. A total of 91 ST‐elevation myocardial infarction patients with thrombolysis in myocardial infarction flow grade of 0 to 1 undergoing primary percutaneous coronary intervention were randomly assigned to a morphine or control group at a 1:1 ratio. The morphine group received 3 mg of morphine sulfate diluted with 3 mL of normal saline, and the control group received 3 mL of normal saline into a coronary artery immediately after restoration of coronary flow. The primary end point was myocardial infarct size assessed by cardiac magnetic resonance imaging The cardiac magnetic resonance images were evaluated for 42 and 38 patients in the morphine and control groups, respectively. Myocardial infarct size was not different between the 2 groups (25.6±11.2% versus 24.6±10.5%, P=0.77), nor was the extent of microvascular obstruction or myocardial salvage index (6.0±6.3% versus 5.1±4.6%, P=0.91; 31.1±15.2% versus 30.3±10.9%, P=0.75, respectively). There was no difference in peak creatine kinase‐MB level, final thrombolysis in myocardial infarction flow, myocardial brush grade, or complete resolution of ST‐segment.

Conclusions

Intracoronary morphine administration could not reduce myocardial infarct size in ST‐elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01738100.

Intracoronary Bivalirudin Bolus in ST-Elevation Myocardial Infarction Patients Treated with Primary Angioplasty: Theoretical Bases, Clinical Experience, and Future Applications

Intracoronary thrombus is a common finding in acute coronary syndromes and often correlates with adverse prognosis and complications during percutaneous coronary interventions (PCIs). Bivalirudin, a direct thrombin inhibitor, is one of the recommended antithrombotic treatments for PCI in ST-elevation myocardial infarction (STEMI). The intracoronary administration of a bivalirudin loading dose, even if off-label, offers theoretical advantages over the standard intravenous route, providing a very high drug concentration in the infarct-related artery without increasing the total dose of the drug administered. After the description in case reports of such an approach, a larger scale experience was recently reported in a large cohort of patients with STEMI treated during primary PCI with a bivalirudin intracoronary loading dose followed by the standard intravenous maintenance infusion. As a control group, a propensity score-matched cohort of patients undergoing primary PCI treated with intravenous bivalirudin in the same institution was selected. Compared with the intravenous bolus, the intracoronary administration of bivalirudin was associated with improved ST-segment resolution, lower post-procedural peak CK-MB levels, and better Thrombolysis in Myocardial Infarction (TIMI) frame count values, without difference in bleeding rates. Thus, this new promising antithrombotic strategy, based on the intracoronary administration of a bivalirudin loading dose during primary PCI, appeared safe, improved myocardial reperfusion, and mitigated enzymatic myocardial infarct size compared with the standard intravenous protocol. Randomized trials are warranted to confirm these results and evaluate the possible long-term clinical benefits.

[Intracoronary administration of antithrombotic agents via a perfusion balloon catheter in patients with ST-segment elevation myocardial infarction presenting with massive intraluminal thrombus and failed aspiration]

BACKGROUND

Massive intracoronary thrombus is associated with adverse procedural results including failed aspiration and unfavourable reperfusion. We aim to evaluate the effect of the intracoronary administration of antithrombotic agents via a perfusion catheter in patients with ST-segment elevation myocardial infarction (STEMI) presenting with a large thrombus burden and failed aspiration.

METHODS

We retrospectively analyzed the thrombus burden, the TIMI grade flow, and the myocardial Blush in 25 consecutive STEMI patients with a large thrombus burden and failed manual aspiration, who received intracoronary infusion of glycoprotein IIb/IIIa inhibitors (N=17) or bivalirudine (N=8) via a 6F-infusion catheter (ClearWay™ RX) RESULTS: Mean age was 67±14 years, 16 patients (64 %) presented with anterior STEMI, and 7 (28 %) with cardiogenic shock. Immediately after intracoronary infusion, the TIMI flow grade improved of 2 grades in 7 patients (28 %), and 1 grade in 14 (56 %), a complete resolution of the thrombus was observed in 9 patients, and a >50 % resolution in 12. Blush was improved of 3 grades in 15 patients (60 %), of 2 grades in 7 (28 %), and Blush grade 0 remained in 3. At the end of procedure, we observed normal TIMI 3flow in most patients (92 %), a complete resolution of thrombus in 80 %, and a Blush grade 3 in 68 %.

CONCLUSIONS

In STEMI patients presenting with a large thrombus burden and failed aspiration, intracoronary administration of glycoprotein IIb/IIIa inhibitors or bivalirudin via the perfusion catheter ClearWay™ RX significantly reduced the thrombus burden and improved the TIMI flow and the Blush grade, without bleeding.

Intracoronary Administration of Abciximab During Percutaneous Coronary Interventions: Should This Be the Routine and Preferred Approach?

The authors have had experience with administering abciximab as an intracoronary bolus in 96 high-risk patients undergoing percutaneous coronary interventions, specifically in situations in which there was anticipation of a high embolic load from thrombus/plaque burden at the site of the culprit lesion, saphenous vein graft culprit lesion, threatened abrupt closure, developing slow-flow, or no-reflow phenomena with distal embolization. Our uncontrolled data basically substantiate the safety of intracoronary administration of abciximab. The data summarizing the potential superiority of this method of administration of the drug and the likely mechanisms of this effect are summarized. These incite a need for reevaluation of the method of administration of the drug, especially in high-risk percutaneous coronary interventions cases

Comparison between the Outcomes of Intracoronary and Intravenous Administration of Eptifibatide during Primary Percutaneous Coronary Intervention in Patients with Acute ST-Elevation Myocardial Infarction

AIM

To compare the outcomes of intracoronary (IC) and intravenous (IV) administration of eptifibatide during primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI).

METHODS

In this prospective double-blind randomized clinical trial, 76 patients with STEMI selected for PPCI were randomly assigned in two groups to receive either IC or IV bolus of eptifibatide. The primary end point was coronary perfusion assessment by thrombolysis in myocardial infarction (TIMI) flow grade (TFG), TIMI perfusion grade (TPG), and corrected TIMI frame count (cTFC). Secondary end points were left ventricular ejection fraction (LVEF) restoration, ST-segment elevation resolution, and in-hospital major cardiovascular adverse events (MACEs) (including recurrent MI, need for target vessel revascularization (TVR), stroke, and death resulting from any cause) until discharge.

RESULTS

Assessment revealed significantly better TFG (95% CI: 1.01-10.26, OR=3.224, P=0.042), more TFG 3 (65.79% vs. 86.11% in IV and IC groups, respectively), better TPG (P=0.024), more achieved TPG 3 and TPG 2＋3 (TPG 3: 44.74% vs. 72.22% and TPG 2＋3: 78.95% vs. 94.44% in the IV and IC groups, respectively) with better cTFC in the IC group (37.33±15.84 vs. 32.53± 20.71 in the IV and IC groups, respectively; P=0.034). LVEF was better restored in the IC group (6.21±8.61% vs. 14.72±5.34% in the IV and IC groups, respectively; P＜0.001) and the ST-segment elevation resolution was better achieved in the IC administration (95% CI: -22.55 to -6.23, P=0.001). There were no recurrent MI, stroke, or need for TVR among patients during the in-hospital stay.

CONCLUSIONS

IC administration of eptifibatide during PPCI in patients with STEMI in comparison with IV administration of eptifibatide is associated with significantly better coronary reperfusion and improved clinical outcomes (IRCT2012090510751N1).

The Combined Effect of Ear Lobe Crease and Conventional Risk Factor in the Diagnosis of Angiographically Diagnosed Coronary Artery Disease and the Short-Term Prognosis in Patients Who Underwent Coronary Stents

The role of diagonal ear lobe crease (DELC) in coronary artery disease (CAD) diagnosis and prognosis remains controversial. In this study, we aimed to assess the combined effect of DELC with other conventional risk factors in the diagnosis and prognosis of CAD in Chinese patients who underwent angiography and coronary stent implantation.The study consisted of 956 consecutive patients who underwent angiography. The DELC was identified as no DELC, unilateral, and bilateral DELC. The conventional risk factors for CAD were recorded.Our dada showed that the overall presence of DELC is associated with CAD risk. Stratification analyses revealed that the diagnostic value of DELC was mostly significant in those with >4 risk factors. Also in patients with >4 risk factors, the presence of bilateral DELC remains to be associated with higher hs-CRP level, higher severity of CAD, and higher possibility of developing major adverse cardiac events after successful percutaneous coronary intervention (PCI).Our study confirmed the relation of DELC with CAD in Chinese patients; more importantly, our data suggest the combination of DELC and CAD risk factors will help to predict the incidence of CAD and may predict the prognosis after successfully PCI.

Intracoronary epinephrine in the treatment of refractory no-reflow after primary percutaneous coronary intervention: a retrospective study

Background

Despite the advances in medical and interventional treatment modalities, some patients develop epicardial coronary artery reperfusion but not myocardial reperfusion after primary percutaneous coronary intervention (PCI), known as no-reflow. The goal of this study was to evaluate the safety and efficacy of intracoronary epinephrine in reversing refractory no-reflow during primary PCI.

Methods

A total of 248 consecutive STEMI patients who had undergone primary PCI were retrospectively evaluated. Among those, 12 patients which received intracoronary epinephrine to treat a refractory no-reflow phenomenon were evaluated. Refractory no-reflow was defined as persistent TIMI flow grade (TFG) ≤2 despite intracoronary administration of at least one other pharmacologic intervention. TFG, TIMI frame count (TFC), and TIMI myocardial perfusion grade (TMPG) were recorded before and after intracoronary epinephrine administration.

Results

A mean of 333 ± 123 mcg of intracoronary epinephrine was administered. No-reflow was successfully reversed with complete restoration of TIMI 3 flow in 9 of 12 patients (75%). TFG improved from 1.33 ± 0.49 prior to epinephrine to 2.66 ± 0.65 after the treatment (p < 0.001). There was an improvement in coronary flow of at least one TFG in 11 (93%) patients, two TFG in 5 (42%) cases. TFC decreased from 56 ± 10 at the time of no-reflow to 19 ± 11 (p < 0.001). A reduction of TMPG from 0.83 ± 0.71 to 2.58 ± 0.66 was detected after epinephrine bolus (p < 0.001). Epinephrine administration was well tolerated without serious adverse hemodynamic or chronotropic effects. Intracoronary epinephrine resulted in significant but tolerable increase in heart rate (68 ± 13 to 95 ± 16 beats/min; p < 0.001) and systolic blood pressure (94 ± 18 to 140 ± 20; p < 0.001). Hypotension associated with no-reflow developed in 5 (42%) patients. During the procedure, intra-aortic balloon pump counterpulsation was required in two (17%) patients, transvenous pacing in 2 (17%) cases, and both intra-aortic balloon counterpulsation and transvenous pacing in one (8%) patients. One patient (8%) died despite all therapeutic measures.

Conclusion

Intracoronary epinephrine may become an effective alternative in patients suffering refractory no-reflow following primary PCI.

Intracoronary abciximab in STEMI using local drug delivery catheter - single center experience

BACKGROUND

Despite restoration of epicardial flow during primary PCI in STEMI, microvascular obstruction may persist as a result of both atheromatous and thrombotic embolization and vasospasm. Compared with the systemic administration of IV pharmaco-therapies, highly localized administration of intracoronary pharmacotherapy may be associated with a several-hundred-fold increase in the local concentration of an agent in the epicardial artery and microcirculation. Despite restoration of epicardial flow during primary PCI in STEMI, microvascular obstruction may persist as a result of both atheromatous and thrombotic embolization and vasospasm. We are presenting our experience with use of intracoronary abciximab using local drug delivery catheter in STEMI patients.

METHODS

We retrospectively evaluated 15 patients presented to us with STEMI undergoing primary PCI between March 2011 and September 2012 who had super selective intracoronary abciximab using local drug delivery catheter. With standard antiplatelet therapy, both Pre and Post TIMI flow, TMP grading were assessed.

RESULTS

Mean age was 55 years. The TIMI flow increased by 3 grades in thirteen patients, TMP grading increased by 2 grades in five patients and by 3 grades in nine patients. Thus TIMI flow and TMP grading improved after super selective intracoronary abciximab.

CONCLUSION

Super selective intracoronary abciximab using local drug delivery catheter during primary PCI in STEMI patients significantly improves TMP grading without increased risk of bleeding. This benefit is achieved even in patients without thrombus aspiration. We need to assess the long-term outcomes in the form of reduction in infarct size using this strategy in large group of patients.

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.

Intracoronary glycoprotein IIb/IIIa inhibitor infusion via a perfusion coronary catheter to decrease thrombus burden: results from the ClearWay™ Multicenter Registry

OBJECTIVES

This multicenter registry aimed to assess the ClearWay™ (CW) perfusion catheter in reduction of thrombus burden and improvement of the coronary flow during percutaneous coronary intervention (PCI).

BACKGROUND

The presence or development of thrombus during PCI is associated with poor prognosis.

METHODS

The utility of the CW perfusion catheter was assessed in patients who presented with intracoronary thrombus and were subjected to PCI. Data were collected by online survey from 15 US sites. Angiographic assessment of the coronary thrombus burden and the coronary flow after intracoronary infusion of glycoprotein (GP) IIb/IIIa inhibitors via the CW catheter was evaluated at baseline, immediately after infusion, and at the end of the procedure. The cohort included 102 patients; 71.6% presented with ST-elevation myocardial infarction (MI), 21.6% with non-ST-elevation MI, 5.9% with stable angina pectoris, and 2.9% with silent ischemia. The mean cohort age was 59.9±14.5years and comprised mostly of men (72.5%).

RESULTS

GP IIb/IIIa inhibitors were infused via the CW catheter on average 1.1±0.3 times, with a mean pressure of 4.2±2.7atm and a mean infusion time of 55±55s. Following the infusion, Thrombolysis In Myocardial Infarction (TIMI) flow improved by 1° in 71 patients (69.6%) and by 2° in 51 patients (50%), while visible thrombus was reduced by 52% (p<0.001). In the final angiogram, TIMI flow was restored in 90.2% and clearance of a visible thrombus was obtained in 91.8% of the lesions.

CONCLUSION

Intracoronary infusion of GP IIb/IIIa inhibitors via the perfusion CW catheter is associated with significant reduction in thrombus burden and with improvement of the coronary flow in patients presenting or developing thrombus burden during PCI.

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.

A comparison of intracoronary with intravenous glycoprotein IIb/IIIa inhibitors during percutaneous coronary intervention in patients with acute coronary syndrome: a meta-analysis of randomized controlled trials

BACKGROUND

It is still debatable whether intracoronary (IC) administration of glycoprotein IIb/IIIa inhibitors (GPIs) is superior to intravenous (IV) administration for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).

METHODS

We performed a meta-analysis of randomized controlled clinical trials. A literature search was conducted for relevant trials. Primary end-points were short-term (1-3 months) and mid-/long-term (6/12 months) major adverse cardiovascular events (MACEs) (mortality, reinfarction, target vessel revascularization [TVR]). Secondary end-points were thrombolysis in myocardial infarction (TIMI) grade flow, TIMI myocardial perfusion grade (TMPG) flow, left ventricular ejection fraction (LVEF) within 2 weeks, and bleeding complication.

RESULTS

Twelve studies were included in the meta-analysis. IC administration of GPIs did not decrease short-term mortality (OR: 0.71, 95% CI: 0.41-1.23, P = 0.22) and reinfarction rate (OR: 0.76, 95% CI: 0.45-1.29, P = 0.31) compared with IV administration. There was a trend toward reduction of short-term TVR rate in IC group compared with IV group but not reaching statistical significance (OR: 0.57, 95% CI: 0.31-1.04, P = 0.07). IC administration of GPIs significantly increased TIMI grade 3 flow (OR: 1.48, 95% CI: 1.06-2.06, P = 0.02) and TMPG grade 2-3 flow (OR: 2.63, 95% CI: 1.53-4.51, P = 0.0004) compared with IV administration. No significant difference was observed in long-term MACEs rate, LVEF, and bleeding complication between the 2 groups.

CONCLUSION

IC administration of GPIs in patients with ACS undergoing PCI can significantly increase target coronary flow and myocardial reperfusion without increasing the risk of bleeding complication, but cannot improve clinical outcome compared with IV administration.

Meta-analysis of prospective randomized controlled trials comparing intracoronary versus intravenous abciximab in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Abciximab is a glycoprotein IIb/IIIa receptor inhibitor that has been shown to improve outcomes in patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention (pPCI). An earlier study reported better efficacy with intracoronary (IC) compared to intravenous (IV) administration, but this finding has not been duplicated in other studies, thus leaving a great deal of uncertainty as to the most efficacious route of administration. To investigate if IC abciximab compared to IV administration decreases mortality and major adverse cardiac events in patients with ST-segment elevation myocardial infarction who undergo pPCI, a meta-analysis was performed consisting only of prospective randomized controlled trials. Subgroup analysis was performed to investigate the source of difference in efficacy between the 2 strategies. A meta-analysis of 4 trials including 1,148 subjects revealed that IC abciximab significantly reduced mortality compared to IV administration (1.5% vs 3.6%, odds ratio 0.44, 95% confidence interval 0.20 to 0.95, p = 0.04). Major adverse cardiac events were also reduced in a subgroup in which <30% of patients received aspiration thrombectomy (6.1% vs 16.2%, odds ratio 0.33, 95% confidence interval 0.18 to 0.61, p = 0.0004). In conclusion, the totality of the data available from relatively small but high-quality studies shows a significant mortality reduction associated using IC abciximab for pPCI compared to IV abciximab. IC abciximab in the setting of pPCI for ST-segment elevation myocardial infarction may be beneficial for patients with higher risk profiles.

Intracoronary versus intravenous high-dose bolus plus maintenance administration of tirofiban in patients undergoing primary percutaneous coronary intervention for acute ST elevation myocardial infarction

We aimed to examine whether intracoronary high-dose bolus of tirofiban plus maintenance would result in improved clinical outcome in STEMI patients undergoing primary PCI in this pilot trial. A total of 56 patients were enrolled to receive either intracoronary high-dose bolus plus maintenance (n = 34) or intravenous high-dose bolus plus maintenance (n = 22) of tirofiban. Pre and post intervention TIMI flow grades, myocardial blush grades, peak CKMB and troponin levels, time to peak CKMB and troponin, time to 50% ST resolution and major composite adverse cardiac event rates at 30 days were recorded. Although incidence of major adverse cardiac events was not different, post intervention TIMI flow and TIMI blush grades, peak CKMB and troponin levels, and time to peak CKMB and time to peak troponin were significantly different, favoring intracoronary strategy. In conclusion, this regimen improved myocardial reperfusion and coronary flow, and reduced myocardial necrosis, but failed to improve clinical outcomes at 30 days.

Glycoprotein IIb/IIIa antagonists

Mortality from ischemic cardiac disease in adults has been dramatically reduced by the development of novel therapies for inhibiting platelet function. Circulating platelets are maintained in a resting state and are activated at sites of vascular injury by exquisitely controlled mechanisms, thereby maintaining vascular integrity without causing intravascular thrombosis. As it became clear that platelets play a central role in arterial thrombosis, the processes of platelet activation, adhesion, and aggregation became logical targets for the development of antithrombotic agents.

Effect of bivalirudin compared with unfractionated heparin plus abciximab on infarct size and myocardial recovery after primary percutaneous coronary intervention: the horizons-AMI CMRI substudy

BACKGROUND

Myocardial infarct size is a strong independent predictor of mortality in patients with ST-elevation myocardial infarction (STEMI). In the Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial, bivalirudin compared with unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor reduced cardiac mortality in STEMI patients, which was attributed to reduced major bleeding. Whether a possible reduction in infarct size with bivalirudin may have contributed to the enhanced survival with this agent is unknown.

METHODS

Cardiac magnetic resonance imaging was performed within 7 days and after 6 months in 51 randomized patients from a single center in HORIZONS-AMI trial (N = 28 bivalirudin, N = 23 heparin plus abciximab). Infarct size, microvascular obstruction (MVO), left ventricular ejection fraction (LVEF), and LV end-diastolic and end-systolic volume indices were evaluated.

RESULTS

Infarct size was not significantly different after treatment with bivalirudin compared with heparin plus abciximab either within 7 days (median 9.3% [interquartile range 4.9%, 26.6%] vs. 20.0% [5.9%, 28.2%], P = 0.28) or at 6 months 6.7% [3.8%, 20.0%] vs. 8.2% [1.8%, 16.5%], P = 0.73). MVO was present in 28.6% versus 34.8% of patients respectively (P = 0.63). LVEF and LV volume indices also did not significantly differ between the two groups at either time period, nor were differences in myocardial recovery evident.

CONCLUSIONS

In conclusion, in the HORIZONS-AMI Cardiac magnetic resonance imaging (CMRI) substudy, cardiac magnetic resonance imaging within 7 days and at 6 months after primary percutaneous coronary intervention (PCI) did not demonstrate significant differences in infarct size, MVO, LVEF, or LV volume indices in patients treated with bivalirudin compared with unfractionated heparin plus abciximab.

Intracoronary versus intravenous abciximab administration in STEMI patients: overview of current status and open questions

OBJECTIVES

To perform a systematic review to provide rationale for intracoronary (IC) abciximab administration in patients with ST-segment elevation myocardial infarction (STEMI), to summarize recent studies comparing IC vs. intravenous (IV) abciximab administration in this setting and to define questions that need to be answered in future trials determining the optimal abciximab regimen.

METHODS

A search covering the period from January 1993 to June 2011 was conducted by two independent investigators using MEDLINE, CENTRAL and Google Scholar databases. Proceedings from the scientific sessions of ACC, AHA, ESC, TCT and EuroPCR were also considered.

RESULTS

IC administration allows one to obtain a much higher concentration of abciximab than IV injection at the culprit lesion. Therefore it is hypothesized that IC abciximab administration provides more efficient GP IIb/IIIa receptor inhibition and more pronounced additional dose-dependent antiplatelet, antithrombotic, and anti-inflammatory effects when compared to the IV route. Numerous observational and randomized studies comparing IC vs. IV abciximab in STEMI patients indicated improvement in different surrogate end points (infarct size, obstruction of coronary microcirculation, ST segment resolution, inflammatory mediators and markers of platelet activation) related to IC administration. The evidence supporting clinical benefits associated with IC injection of abciximab comes from one randomized and several non-randomized trials as most of the studies were underpowered to assess clinical outcomes. No difference in bleeding complications was observed between IC and IV regimens. Issues that need to be addressed in future studies include: the use of IC abciximab in combination with thrombectomy, the role of selective delivery systems, and the necessity of a prolonged IV infusion of abciximab after IC bolus administration.

CONCLUSIONS

An accumulating body of evidence suggests the superiority of IC over IV abciximab administration in STEMI patients. However, further trials are warranted to establish the optimal strategy of abciximab treatment in this setting.

Meta-analysis of randomized controlled trials of intracoronary versus intravenous administration of glycoprotein IIb/IIIa inhibitors during percutaneous coronary intervention for acute coronary syndrome

It is unclear whether intracoronary (IC) bolus administration of glycoprotein IIb/IIIa inhibitors (GPIs) during percutaneous coronary intervention (PCI) in patients with acute coronary syndromes is superior to intravenous (IV) administration. We conducted a meta-analysis of randomized controlled trials (RCTs) to compare the effects of IC and IV administrations of GPIs in patients with acute coronary syndromes. We systematically searched the Cochrane Library, EMBASE, and MEDLINE databases for RCTs comparing IC to IV administration of GPIs (abciximab, eptifibatide, tirofiban) during PCI. Data were pooled and stratified into short (1 month to 3 months) and mid-/long-term (≥6 months) follow-up durations. Ten RCTs involving 1,590 patients met our inclusion criteria. Compared to the IV group the IC group was more likely to have complete perfusion (Thrombolysis In Myocardial Infarction grade 3 flow) after PCI (risk ratio [RR] 1.08, 95% confidence interval [CI] 1.02 to 1.15). IC administration was associated with similar bleeding rates as IV (RR 0.92, 95% CI 0.68 to 1.24) but with a significant decrease in short-term target vessel revascularization (RR 0.54, 95% CI 0.30 to 0.96). IC administration was also associated with a significant decrease in short-term mortality (RR 0.45, 95% CI 0.23 to 0.90) but this decrease was no longer significant in mid-/long-term RCTs. In conclusion, compared to IV administration IC administration of GPIs has favorable effects on Thrombolysis In Myocardial Infarction flow, target vessel revascularization, and short-term mortality after PCI, with no difference in rates of bleeding. Data regarding mid-/long-term outcomes were limited and inconclusive. Large RCTs with longer follow-up are required to determine long-term safety and efficacy.

The Optimal Route of Administration of the Glycoprotein IIb/IIIa Receptor Antagonist Abciximab During Percutaneous Coronary Intervention; Intravenous Versus Intracoronary

The use of the glycoprotein (GP) IIb/IIIa receptor antagonist Abciximab has over the years become an important part of the anticoagulant regimen in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Abciximab is a potent inhibitor of platelet aggregation and thrombus formation, but other mechanisms, such as suppression of the inflammatory pathways, have also been proposed to contribute to the benefits of Abciximab.

The optimal route of administration, i.e. intravenous versus intracoronary, of the first dose has been questioned, but only tested in small, non-randomised and retrospective studies or studies with short follow-up. No definite conclusion can be made based on these studies.

In this review we present the current knowledge published about the intracoronary administration of Abciximab including the mechanisms behind the potential beneficial effects, and the safety. The emphasis will be on clinical trials rather than on studies on the pharmacological mechanisms, as the latter have been reviewed thoroughly elsewhere.

Our conclusion from this present review is that randomized trials of intracoronary versus intravenous bolus of Abciximab are needed.

[Management of acute myocardial infarction. How improve primary angioplasty?]

Besides the reduction of the delay for the myocardium reperfusion, the revascularization must be optimized by tools and techniques of percutaneous intervention. These are pharmacological, mechanical and procedural. The appeal to antiGP2b3a can be useful in the cathlab. Its intracoronary administration seems to improve drug efficiency. Among the protection devices against the coronary clot embolism, only thrombectomy by manual aspiration gives an evidence of its efficiency. During the primary angioplasty, the drug eluting stent could to be implanted only for the patients and the lesions with high risk of TLR. In some cases, still difficult to identify, a more controlled revascularization would allow to minimize the reperfusion injury. The radial access, decreasing the rate of haemorrhagic complications, must be preferred in first intention.

Rationale and design of the INFUSE-AMI study: A 2 × 2 factorial, randomized, multicenter, single-blind evaluation of intracoronary abciximab infusion and aspiration thrombectomy in patients undergoing percutaneous coronary intervention for anterior ST-segment elevation myocardial infarction

BACKGROUND

Whether thrombus aspiration and local glycoprotein IIb/IIIa administration reduce infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) has not been established in multicenter studies.

DESIGN

INFUSE-AMI is a multicenter, open-label, controlled, single-blind randomized study enrolling 452 subjects with anterior STEMI and an occluded proximal or mid-left anterior descending artery with thrombosis in myocardial infarction 0, 1, or 2 grade flow undergoing primary PCI with bivalirudin anticoagulation. Subjects are randomized in a 2 × 2 factorial to one of the following 4 arms: (1) local infusion of abciximab using the ClearWay RX Local Therapeutic Infusion Catheter (ClearWay, Atrium Medical Corp, Hudson, NH) after aspiration with a 6F Export Aspiration Catheter (Medtronic, Inc, Minneapolis, MN), (2) local infusion of abciximab using the ClearWay RX Infusion Catheter and no aspiration, (3) no local infusion of abciximab and aspiration with a 6F Export Aspiration Catheter, or (4) no local infusion of abciximab and no aspiration. The primary end point is infarct size (percentage of total left ventricular mass) at 30 days measured by cardiac magnetic resonance imaging. Other secondary end points include microvascular obstruction by cardiac magnetic resonance imaging at 5 days, ST-segment resolution, angiographic myocardial perfusion, thrombus burden, angiographic complications, and clinical events through 1-year follow-up. Safety end points include major and minor bleeding.

SUMMARY

INFUSE-AMI is testing the hypothesis that the intracoronary administration of an abciximab bolus with or without thrombus aspiration before stent implantation compared to no infusion with or without thrombus aspiration reduces infarct size among patients undergoing primary PCI for anterior STEMI who are treated with bivalirudin.

Local delivery versus intracoronary infusion of abciximab in patients with acute coronary syndromes

OBJECTIVES

We investigated whether local abciximab delivery to the site of intracoronary thrombus is more effective than intracoronary bolus infusion in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention and downstream clopidogrel administration.

BACKGROUND

The intracoronary route of administration does not allow an optimal contact between the plaque components and abciximab, which is rapidly washed out by the coronary flow.

METHODS

A total of 50 patients with ACS and a significant lesion in the culprit artery indicative of local thrombosis were randomly assigned to receive local intracoronary delivery of abciximab through a dedicated perfusion catheter or intracoronary infusion through the guiding catheter. The primary end point was the change in thrombus score after angioplasty by optical coherence tomography.

RESULTS

After the intervention, the mean percentage change of the thrombus score was significantly higher among patients of the local delivery group compared with those of the intracoronary infusion group (33.8% vs. 3.9%, p = 0.002). Post-procedural corrected Thrombolysis in Myocardial Infarction frame count was shorter in the local delivery group compared with the intracoronary infusion group (15.3 ± 10.2 vs. 21.1 ± 9.9, p = 0.049). Procedure-related myocardial infarction was observed in 10% and 43% of patients in the local delivery and intracoronary infusion groups, respectively (p = 0.018). At 1 year, MACE were observed in 5.9% and 27.2% of patients in the local delivery and intracoronary infusion groups, respectively (p = 0.046).

CONCLUSIONS

Local intracoronary delivery of abciximab by means of a dedicated perfusion catheter reduces thrombus burden with the potential to improve coronary microcirculation.

Intracoronary versus intravenous bolus abciximab application in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: 6-month effects on infarct size and left ventricular function. The randomised Leipzig Immediate PercutaneouS Coronary Intervention Abciximab i.v. versus i.c. in ST-Elevation Myocardial Infarction Trial (LIPSIAbciximab-STEMI)

BACKGROUND

Administration of abciximab during primary percutaneous coronary intervention (PCI) reduces major adverse cardiac events (MACE) in patients with ST-elevation myocardial infarction (STEMI). Intracoronary (IC) abciximab bolus application during PCI results in high local drug concentration, improved perfusion, reduction of infarct size, and less microvascular obstruction early after infarction. Aim of this study was to investigate whether the early benefits of an IC abciximab administration in STEMI patients undergoing PCI are sustained at 6 months.

METHODS

We performed 6-month follow-up of 154 STEMI patients undergoing PCI, who were randomised to either IC (n = 77) or intravenous (IV) (n = 77) bolus abciximab administration with subsequent 12-h intravenous infusion. The primary endpoint was infarct size at 6-month follow-up as assessed by delayed enhancement magnetic resonance imaging. Clinical end points were MACEs within 6 months after infarction.

RESULTS

The median infarct size after 6 months was significantly reduced in the IC abciximab group (16.7 vs. 24.1%, p = 0.002). A significant recovery of LV function was only observed in the IC abciximab group (p < 0.001), and IC abciximab group patients had significantly less adverse remodelling as compared to standard IV abciximab treatment (p = 0.03). These beneficial effects also translated into a strong trend towards a reduced MACE rate in the IC abciximab group at 6-month follow-up (10 vs. 21%, p = 0.07).

CONCLUSIONS

Intracoronary abciximab application in STEMI patients undergoing PCI is superior to standard IV treatment with respect to infarct size, recovery of LV function and reverse remodelling 6 months after infarction.

Intracoronary compared to intravenous Abciximab and high-dose bolus compared to standard dose in patients with ST-segment elevation myocardial infarction undergoing transradial primary percutaneous coronary intervention: a two-by-two factorial placebo-controlled randomized study

Platelet aggregation inhibition (PAI) of > or =95% has been associated with improved outcomes after percutaneous coronary intervention (PCI) and glycoprotein IIb/IIIa inhibitor treatment. A greater thrombotic burden in acute ST-segment elevation myocardial infarction (STEMI) might require higher doses and/or intracoronary delivery of glycoprotein IIb/IIIa inhibitors to achieve optimal PAI. Using a 2 x 2 factorial placebo-controlled design, 105 patients with STEMI who had been referred for primary PCI within 6 hours of symptom onset were randomized to intracoronary (IC) or intravenous (IV) delivery of an abciximab bolus at a standard dose (0.25 mg/kg) or high dose (> or =0.30 mg/kg) of abciximab. The primary end point was PAI measured at 10 minutes after the bolus of abciximab. Secondary end points included the acute and 6-month outcomes using angiographic parameters, cardiac biomarkers, cardiovascular magnetic resonance imaging, and clinical end points. At 10 minutes after the bolus, the proportion of patients with > or =95% PAI was not different between the IC and IV groups (53% vs 54%, p = 1.00) nor between the high-dose and standard-dose bolus groups (56% vs 51%, p = 0.70). Acutely, the angiographic myocardial blush grades, peak release of cardiac biomarkers, necrosis size, myocardial perfusion, and no reflow as assessed by magnetic resonance imaging, and clinical end points were similar between the groups and did not suggest a benefit for IC compared to IV or high-dose versus standard-dose bolus of abciximab. No increase occurred in bleeding complications with the high-dose bolus or IC delivery. The clinical, angiographic and cardiac magnetic resonance imaging outcomes at 6 and 12 months were similar between the 4 groups. In conclusion, in patients with STEMI presenting with symptom onset <6 hours and undergoing transradial primary PCI, PAI remained suboptimal, despite a higher dose bolus of abciximab. A higher dose bolus or IC delivery of abciximab bolus was not associated with improved acute or late results compared to the standard IV dosing and administration.