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Published on: January 18, 2018
Comparison of reperfusion regimens with or without tirofiban in ST-elevation acute myocardial infarction
Marco A Martínez-Ríos1, Martín Rosas, Héctor González
1National Institute of Cardiology, Mexico City, Mexico. mtzrios@cardiologia.org.mx
Insights
Adding tirofiban to reperfusion therapy for ST-elevation acute myocardial infarction (AMI) improves blood flow and patient outcomes. This platelet glycoprotein IIb/IIIa inhibitor enhances myocardial reperfusion without increasing bleeding risk.
Area of Science:
- Cardiology
- Interventional Cardiology
- Pharmacology
Background:
- Optimal myocardial reperfusion in ST-elevation acute myocardial infarction (AMI) remains a challenge.
- The role of platelet glycoprotein IIb/IIIa inhibitors in conjunction with reperfusion strategies is debated.
- Angiographic assessment of myocardial reperfusion requires standardized methods.
Purpose of the Study:
- To evaluate the efficacy of a combined reperfusion regimen with low-dose alteplase and tirofiban versus standard therapy in patients with AMI.
- To compare the effectiveness of tirofiban combined with stenting percutaneous coronary intervention (PCI) versus standard stenting PCI.
- To assess the impact of these strategies on Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow, TIMI myocardial perfusion (TMP) rates, and clinical outcomes.
Main Methods:
- A randomized trial involving 144 patients with first AMI presenting within 6 hours of symptom onset.
- Patients were assigned to either a conjunctive strategy (low-dose alteplase + tirofiban or tirofiban + stenting PCI) or a standard strategy (full-dose alteplase or stenting PCI).
- Coronary angiography was performed at 90 minutes to assess TIMI grade 3 flow and TMP rates. A 30-day composite endpoint was also evaluated.
Main Results:
- The conjunctive strategy with low-dose alteplase and tirofiban achieved a TIMI 3 flow rate of 64%, compared to 42% with alteplase alone.
- Tirofiban combined with stenting PCI resulted in a 92% TIMI 3 flow rate, versus 81% for standard stenting PCI.
- Significantly higher TMP grade 3 rates were observed with tirofiban use (66% vs. 47% for alteplase, 73% vs. 55% for PCI).
- The conjunctive regimens showed a significantly lower 30-day composite endpoint (HR 5.8, p=0.023).
- Major bleeding rates were similar between standard and conjunctive regimens (2.8%).
Conclusions:
- Tirofiban as adjunctive therapy improves both TIMI 3 flow and TMP rates in AMI reperfusion, regardless of whether lytic therapy or stenting PCI is used.
- Achieving both TIMI 3 flow and TMP grade 3 is associated with better clinical outcomes.
- The addition of tirofiban to reperfusion strategies enhances microcirculatory function and clinical outcomes without increasing bleeding risk.
Abstract:
There is continued debate as to whether a combined reperfusion regimen with platelet glycoprotein IIb/IIIa inhibitors provides additional benefit in optimal myocardial reperfusion of patients with a ST-elevation acute myocardial infarction (AMI). In addition, the best angiographic method to evaluate optimal myocardial reperfusion is still controversial. Patients (n = 144) with a first AMI presenting <6 hours from onset of symptoms were randomized to receive a conjunctive strategy (n = 72) with low-dose alteplase (50 mg) and tirofiban (0.4 microg/kg/min/30 minute bolus; infusion of 0.1 microg/kg/minute), or tirofiban plus stenting percutaneous coronary intervention (PCI). Control patients (n = 72) received standard strategy with either full-dose alteplase (100 mg) or stenting PCI [correction]. All patients were submitted to coronary angiographic study at 90 minutes. The primary end point was Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow at 90 minutes. Secondary end points were TIMI myocardial perfusion (TMP) rates, a composite end point at 30 days (death, reinfarction, refractory ischemia, stroke, heart failure, revascularization procedures, or pulmonary edema), and bleeding or hematologic variables. The rate of TIMI 3 flow at 90 minutes for patients treated with alteplase alone was 42% compared with 64% for those who received low-dose alteplase and tirofiban. Standard stenting PCI achieved 81% of TIMI 3 flow compared with 92% when tirofiban was used. Significantly higher rates of TMP grade 3 were observed when tirofiban was used as the adjunctive treatment in both alteplase (66% vs 47%) and stenting PCI (73% vs 55%). Higher rates of the composite end point were observed in standard regimens compared with conjunctive regimens (hazard ratio 5.8, 95% confidence interval 1.27 to 26.6, p = 0.023). Regardless of reperfusion regimen, better outcomes were observed when a combination of TIMI 3 flow and TMP grade 3 was achieved. Beyond TIMI 3 flow rate, the TMP grade was an important determinant. The rates of major bleeding were similar (2.8%) for standard versus conjunctive regimens with tirofiban. Thus, tirofiban as a conjunctive therapy for lytic and stenting regimens not only improves TIMI 3 flow rates, but also the TMP3 rates, which are related to a better clinical outcome without an increase in the risk of major bleeding. This study supports the hypothesis that platelets play a key role not only in the atherothrombosis process, but also in the disturbances of microcirculation and tissue perfusion.