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Fibrinolysis Plus GP IIb/IIIa Inhibitors Before PCI for STEMI?

Treatment with half-dose reteplase plus abciximab provided no advantage over treatment with abciximab alone.

Percutaneous coronary intervention (PCI) is the preferred mode of acute management for ST-segment-elevation myocardial infarction (STEMI). At issue is whether administration of a glycoprotein IIb/IIIa inhibitor and a fibrinolytic agent before PCI improves outcome compared with administration of a GP IIb/IIIa inhibitor alone. In an open-label, randomized, controlled study, funded by several pharmaceutical companies, researchers compared half-dose reteplase plus standard-dose abciximab with standard-dose abciximab alone; assigned drugs were administered before PCI to patients in whom STEMI was diagnosed within 12 hours after symptom onset. Of the 253 patients, 186 were enrolled in the study at 13 community hospitals and transferred to 1 of 5 hospitals with PCI capabilities; the remaining 67 patients were enrolled at the PCI-capable hospitals.

Final infarct size of the left ventricle (the primary outcome), as assessed by single-photon-emission computed tomography at 5 to 10 days after randomization, was not significantly different between the reteplase/abciximab and abciximab-alone groups (13.0% vs. 11.5%). The two secondary outcome measures -- major bleeding complications (5.6% vs. 1.6%) and a composite of death, recurrent MI, and stroke within 6 months (6.4% vs. 4.7%) -- also did not differ significantly between groups.

Comment: GP IIb/IIIa inhibitors have antiplatelet and anti-inflammatory properties that might improve epicardial blood flow. Fibrinolytic agents are intended to unclog the infarct-related coronary artery. These results did not demonstrate an advantage of administering both types of agents together compared with administering a GP IIb/IIIa inhibitor alone. However, the study cohorts might have been too small to provide adequate power for comparison. We should await the results of the ongoing FINESSE and ASSENT-4 trials, in which multiple pharmaceutical strategies for bridging the delay to PCI are being compared in large numbers of subjects.

— John A. Marx, MD, FACEP

Published in Journal Watch Emergency Medicine March 31, 2004

Citation(s):

Kastrati A et al. Early administration of reteplase plus abciximab vs abciximab alone in patients with acute myocardial infarction referred for percutaneous coronary intervention: A randomized controlled trial. JAMA 2004 Feb 25; 291:947-54.

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