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3.3%

4.0%

10.9%

15.7%

aAuthor: provide footnote aAuthor: provide footnote

Fig. 16. Six-month incidence of ischemic complications following randomization to stent or balloon angioplasty in acute MI. Adapted from refs. 58-63.

As coronary stent implantation became the preferred modality of revascularization after the deployment technique and adjunctive dual antiplatelet were perfected, seven randomized trials of stent implantation (and one consecutive series) in acute MI were completed (56-63) (Table 4). Important differences existed among the studies with respect to methodology, follow-up, and rate of cross-over. Nevertheless, in aggregate, the results indicate that, at least in low-risk patients, the mortality is very low in both arms and stenting is more effective in preventing reinfarction and repeat infarct artery revascularization (Fig. 16). There was initial concern that deployment of a bulky stent in a thrombus-laden vessel at high pressure would increase the extent of distal embolization and reduce the rate of TIMI 3 flow, as suggested by the STENT PAMI and STEN-TIM-2 trials.

A partial solution to the problem of distal embolization was offered by the use of aggressive platelet inhibition with glycoprotein IIb/IIIa antagonists. First observed in a small cohort of patients with evolving acute MI in the Evaluation of c7E3 for the Prevention of Ischemic Complications (EPIC) study (64), the benefit of abciximab therapy during primary angioplasty was confirmed in four randomized clinical trials: The Neumann

Fig. 17. Thirty-day ischemic events in trials of primary angioplasty with or without abciximab. Adapted from refs. 63 and 65-67.
Fig. 18. Incidence of death at 6 mo in the CADILLAC and ADMIRAL trials. Adapted from refs. 63 and 67.

(Munich) trial, ReoPro and Primary PTCA Organization and Randomized Trial (RAPPORT), Abciximab before Direct Angioplasty and Stenting in Myocardial Infarction Regarding Long-Term Follow-up (ADMIRAL), and Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) (63,65-67). The incidence of major ischemic events at 30 d was reduced in all trials by abciximab, as shown in Fig. 17. Nevertheless, there was substantial heterogeneity in 6-mo outcome, particularly between the ADMIRAL and CADILLAC studies. Fig. 18 illustrates these differences and highlights the difficulty of comparisons across trials. In ADMIRAL, patients with cardiogenic shock (8%, mortality nearly 80%) were enrolled, while the presence of cardiogenic shock was an exclusion criterion in CADILLAC. Furthermore, nearly a quarter of patients in ADMIRAL received abciximab before angiography, a practice not permitted in CADILLAC. Indeed, the benefit of abciximab was particularly evident in the early treatment group suggesting facilitation of the coronary intervention. Altogether, it appears that abciximab adjunctive therapy reduces early ischemic complications such as abrupt closure, stent thrombosis, and reinfarction. Its long-term benefit is directly dependent upon the acuity of the population treated.

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