Impact of early abciximab administration on infarct size in patients with ST-elevation myocardial infarction

https://doi.org/10.1016/j.ijcard.2010.09.094Get rights and content

Abstract

Background

Early abciximab administration in patients requiring transportation to undergo primary percutaneous coronary intervention (PPCI) has been reported to improve clinical outcome. We aimed to verify whether early administration leads to reduced infarct size (IS), assessed by delayed-enhancement magnetic resonance imaging (DE-MRI).

Methods

We randomized 110 patients with acute myocardial infarction with symptom-to-diagnosis time < 6 h to either early (55 patients) or late (55 patients) abciximab administration. DE-MRI was performed at 4 days and 6 months. The primary end point was IS at 6 months. Secondary end points were the rate of ST-segment elevation resolution ≥ 50% (STR) at 60 min after PPCI, the extent of microvascular obstruction at 4 days, and the change in IS and transmurality at 6 months vs. 4 days.

Results

DE-MRI was performed in 103 patients after 4 days, and in 87 at 6 months. The mean IS at 6 months was 13.8 ± 9.0% in the early vs. 13.0 ± 9.9% in the Late group (P > 0.2). Similarly, microvascular obstruction and the change in IS were not significantly different. The Early group showed a significantly higher STR (94.5% vs. 80.0%, P = 0.04) and a larger reduction in infarct transmurality (− 9.2 ± 7.0% vs. − 5.9 ± 6.4%; P = 0.03), while a larger reduction in IS was observed only in patients with ECG-to-Cath Lab time > 60 min.

Conclusions

Early abciximab administration did not lead to a smaller IS at 6-month DE-MRI, and was associated with a significant reduction in IS and transmurality only in patients with longer transportation time, warranting further investigation in this patient subset.

Introduction

In patients with acute ST-elevation myocardial infarction (STEMI), our efforts to provide an effective myocardial reperfusion through primary percutaneous coronary intervention (PCI) are often frustrated by patient-related delay to presentation, and by logistical difficulties leading to prolonged door-to-balloon time. In order to anticipate the reperfusion of the infarct-related artery (IRA), different strategies of pharmacological facilitation of primary PCI have been evaluated.

Regarding facilitation with glycoprotein IIb/IIIa inhibitors, small randomized trials and a recent meta-analysis demonstrated that early abciximab administration improves coronary patency pre-PCI, myocardial perfusion post-PCI, and 1-month left ventricular function recovery [1], [2], [3]. However, in the large randomized FINESSE trial, facilitation with abciximab alone did not significantly improve the clinical outcomes [4].

Delayed-enhancement magnetic resonance imaging (DE-MRI) is currently the gold standard to assess myocardial tissue reperfusion. The aim of this randomized trial was to evaluate the effects of early vs. late abciximab administration on infarct size (IS) and microvascular obstruction (MVO) assessed by DE-MRI.

Section snippets

Population

We randomly assigned in an open-label fashion 110 consecutive patients with STEMI who needed ambulance transportation to undergo primary PCI to either early (i.e. in the emergency room) or late (i.e. in the catheterization laboratory) abciximab administration. After obtaining the qualifying ECG and the written informed consent from the patient, randomization was performed with a 1:1 ratio by an internet-based randomization system. Inclusion criteria were: (1) presence of ST-segment elevation ≥ 

Population

Of the 110 patients enrolled, 55 were randomized to early and 55 to late abciximab administration. The flow of participants through the study is represented in Fig. 2. A complete MRI assessment both at baseline and at 6-month follow-up was available in 44 patients in the Early group, and in 43 in the Late group.

The baseline clinical characteristics were similar between groups, except for a trend to a worse LV ejection fraction on admission in the Early group (Table 1). About 50% of patients in

Discussion

This randomized trial was planned to verify whether the early administration of abciximab before transportation to the catheterization laboratory is superior to the late administration in reducing IS, as assessed by DE-MRI at 6 months. We chose DE-MRI as the most sensitive method to assess IS in both the acute and chronic settings, allowing for precise quantification of the presence, location, and extent of myocardial infarction, and of microvascular obstruction [9], [15], [16], [17].

Our trial

Acknowledgments

We gratefully acknowledge A. Baratta (118 Network Massa), V. Bonatti (Massa Hospital), G. Casolo (Versilia Hospital), M. Cozzalupi (Fivizzano-Pontremoli Hospital), C. Giustarini (Volterra Hospital), R. Melandri (Emergency Department, Azienda Ospedaliero-Universitaria Pisana), A. Pucci (Carrara Hospital), G. Tartarini (Pontedera Hospital) for their cooperation.

The present trial was an academic research project which was partially supported by an unrestricted research grant from Eli Lilly and

References (26)

  • J. Godicke et al.

    Early versus periprocedural administration of abciximab for primary angioplasty: a pooled analysis of 6 studies

    Am Heart J

    (2005)
  • G. De Luca et al.

    Early glycoprotein IIb–IIIa inhibitors in primary angioplasty (EGYPT) cooperation: an individual patient data meta-analysis

    Heart

    (2008)
  • S.G. Ellis et al.

    Facilitated PCI in patients with ST-elevation myocardial infarction

    N Engl J Med

    (2008)
  • Cited by (15)

    • A multi target and multi timing strategy for the management of coronary microvascular obstruction

      2018, Coronary Microvascular Obstruction in Acute Myocardial Infarction: From Mechanisms to Treatment
    • Prevention of coronary microvascular obstruction by addressing the individual susceptibility

      2018, Coronary Microvascular Obstruction in Acute Myocardial Infarction: From Mechanisms to Treatment
    • Efficacy and safety of early versus late glycoprotein IIb/IIIa inhibitors for PCI

      2013, International Journal of Cardiology
      Citation Excerpt :

      A total of 895 patients in seven trials received oral administration of the loading dose of clopidogrel prior to PCI. Four trials were conducted on a loading dose of 600 mg (n = 660, 73.7%) [19–21,24], one trial on a loading dose of 450 mg (n = 114, 12.7%) [32] and two trials on a loading dose of 300 mg (n = 121, 13.5%) [27,33]. Data were available in 19 trials.

    View all citing articles on Scopus
    View full text