A study published early online in the journal JAMA concludes that patients who received angioplasty after a heart attack and who received stents that released the drug sirolimus were much less likely to experience major adverse cardiac events in the following 8 months compared to those patients who received uncoated stents. Marco Valgimigli, M.D., Ph.D., (Cardiovascular Institute, University of Ferrara, Italy) and colleagues also found that patients who received the anticoagulants abciximab and tirofiban had similar outcomes for some cardiac measures within 90 minutes after the angioplasty.
In order to reduce major adverse cardiac events (MACE) in patients who undergo angioplasty or percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI – a particular electrocardiogram pattern that follows a heart attack), it is common for physicians to implant an uncoated stent in the patient and infuse with the anticoagulant abciximab. The researchers were interested in testing if using tirofiban instead of abciximab could results in similar benefits as well as clinical and economic benefits. When using drug-releasing stents instead of uncoated stents, doctors are less likely to continually open obstructed blood vessels after elective PCI. However, drug-releasing stents are often not used due to questionable efficacy results and other safety concerns.
Valgimigli and colleagues used a sample of 745 patients from Italy, Spain and Argentina who had STEMI and were undergoing PCI. Between October 2004 and April 2007, the researchers evaluated the effect of high-dose tirofiban and sirolimus-releasing stents compared with abciximab infusion and uncoated-stent implantation.
Results showed that 722 patients (97%) had interpretable electrocardiograms. Among these, at least a 50% resolution of ST-segment elevation 90 minutes after PCI was noted in 83.6% (302 of 361 patients) of patients in the abciximab group and 85.3% (308 of 361 patients) of patients in the tirofiban group. The researchers also noted similar outcomes regarding ischemic and hemorrhagic outcomes in the two groups.
MACE rates were analyzed 8 months after PCI. For those who received tirofiban, 9.9% had MACE, and for those who received abciximab, 12.4% had MACE. Patients who had uncoated stents had a higher rate of MACE – 54 patients, or 14.5%. Patients who were treated with the sirolimus-releasing stent had comparatively lower MACE rate – 29 patients, or 7.8%. Patients who received the sirolimus-releasing stent were also much less likely to require revascularization (repeat procedure to unblock a blood vessel) – 10.2% with the uncoated stent compared with 3.2% with sirolimus-releasing stent.
The authors conclude: “In summary, our study provides evidence that in a broad population of largely unselected patients undergoing PCI for STEMI, tirofiban therapy is associated with a noninferior resolution from ST-segment elevation at 90 minutes postintervention compared with abciximab, and at 8-month follow-up, MACE are approximately halved by sirolimus-eluting stent implantation compared with uncoated stents.”
Comparison of Angioplasty With Infusion of Tirofiban or Abciximab and With Implantation of Sirolimus-Eluting or Uncoated Stents for Acute Myocardial Infarction: The MULTISTRATEGY Randomized Trial
Marco Valgimigli; Gianluca Campo; Gianfranco Percoco; Leonardo Bolognese; Corrado Vassanelli; Salvatore Colangelo; Nicoletta de Cesare; Alfredo E. Rodriguez; Maurizio Ferrario; Raul Moreno; Tommaso Piva; Imad Sheiban; Giampaolo Pasquetto; Francesco Prati; Marco S. Nazzaro; Giovanni Parrinello; Roberto Ferrari
JAMA (2008). 299 Vol. 15.
doi:10.1001/jama.299.15.joc80026
Written by: Peter M Crosta