Info

Eptifibatide

TNK-tPA

67% N/A

favoring rescue angioplasty over conservative management (78). These data reflect mostly the work done in the 1980s and early 1990s, when the success of rescue angioplasty was only 80-90% (TIMI 3 flow without reinfarction). More recently, in the GUSTO III trial (79), patients undergoing rescue angioplasty had a lower mortality at 30 d when abciximab was added compared with standard anticoagulation with heparin (3.6 vs 9.7%, p = 0.04). Data from the TIMI 14 study confirm that rescue angioplasty is safe in patients with failed lysis, resulting in a mortality of 5.5% and an incidence of ischemic events of 10.7% at 30 d, considerably better than in historical series of rescue angioplasty (80).

As primary angioplasty is available around the clock in a minority of centers in the United States and the importance of arterial patency before angioplasty has been well established (23,81), strategies geared to achieve arterial patency and thus facilitate angioplasty are intensely studied.

Reduced-dose fibrinolysis as a prelude to angioplasty has been studied in the Plas-minogen-activator Angioplasty Compatibility Trial (PACT) (82). It compared the administration of single-bolus tPA (50 mg) or placebo followed by immediate angiography and rescue angioplasty (if TIMI < 3 flow exists) or completion of the pharmacological regimen if normal flow was present. While patients receiving 50 mg tPA had a higher rate of TIMI 2 + 3 flow on initial angiogram than those allocated to placebo (61 vs 34%, p < 0.001), there was no difference in the final rate of TIMI 3 flow after rescue angioplasty for TIMI < 3 flow (77 and 79%, respectively). At 30 d, there was no difference in mortality (3.6 vs 3.3%), reinfarction (3.0 vs 2.6%), or major bleeding (12.6 vs 13.5%) between the tPA and placebo groups, respectively. The patients with best recovery of systolic function were those with TIMI 3 flow on arrival to angiography, regardless of whether it was spontaneously achieved or pharmacologically induced.

A more successful strategy to facilitate angioplasty was the combination of reduced dose fibrinolytics and GP IIb/IIIa inhibitors. In four small angiographically controlled trials (Table 5), the combination regimens improved speed and quality of reperfusion compared to standard-dose fibrinolysis (83-86). They also provided important information on the feasibility and utility of facilitated angioplasty. In the Strategies for Patency Enhancement in the Emergency Department (SPEED) trial, 323 patients underwent early catheter-based reperfusion after the protocol-mandated control angiography at 60 min, and 123 did not (87). Compared to patients treated conservatively, those undergoing facilitated angioplasty had significantly less reinfarction, (1.2 vs 4.9%, p =

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Fig. 21. Clinical outcome of patients undergoing facilitated angioplasty or treated conservatively after combination platelet and fibrin lysis. Reproduced with permission from ref. 87.

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Days from Randomization

Fig. 21. Clinical outcome of patients undergoing facilitated angioplasty or treated conservatively after combination platelet and fibrin lysis. Reproduced with permission from ref. 87.

0.003) and a significantly lower incidence of death, reinfarction, or urgent revascularization (Fig. 21). Patients receiving the combination of abciximab and low-dose reteplase (rPA) had a significantly higher incidence of TIMI 3 flow before angioplasty than those receiving abciximab alone or full dose rPA (47 vs 24 vs 39%, p = 0.05, respectively) as well as a higher incidence of major bleeding (8.8 vs 2.7 vs 3.6%, respectively, p = 0.24).

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