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Integrating Coronary Stents and Glycoprotein IIb/IIIa Inhibitors into a Mechanical Reperfusion Strategy

The CADILLAC and ADMIRAL Trials

  • Chapter
Primary Angioplasty in Acute Myocardial Infarction

Part of the book series: Contemporary Cardiology ((CONCARD))

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Abstract

The pathogenesis of acute myocardial infarction (AMI) is characterized by atherosclerotic plaque rupture, platelet activation and aggregation, and resultant thrombus formation (1,2). Whether the thrombotic mass becomes occlusive, subocclusive, or nonobstructive (in concert with other variables such as collateral flow, baseline left ventricular function, amount of myocardium at risk, diabetes, etc.) will determine whether the clinical presentation is one of severe chest pain with ST-segment elevation, unstable angina, mild angina, or absent symptoms. Restoring effective myocardial perfusion and metabolism is fundamental to limiting infarct size and enhancing survival. Reperfusion therapy for AMI may be achieved by either the systemic administration of fibrinolytic therapy or primary (formerly called direct) percutaneous transluminal coronary angioplasty (PTCA). Despite its widespread availability and proven efficacy (3), fibrinolytic therapy is limited by the failure to achieve normal antegrade Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow in 40% or more of patients; early and late reocclusion of the infarct vessel in approx 10% and 30% of patients, respectively; and iatrogenic hemorrhagic risks, including intracranial bleeding, in approx 1% of patients (4–8). Alternatively, the timely performance of primary PTCA offers the advantages of anatomic definition, higher rates of patency and TIMI 3 flow, and virtually eliminates the risk of intracranial hemorrhage (9), although the majority of hospitals in the United States do not have the invasive facilities for emergency cardiac catheterization and intervention (10). Nonetheless, more than 10 randomized trials comparing fibrinolytic therapy to primary PTCA (mostly balloon angioplasty) have clearly demonstrated a clinically meaningful and statistically significant reduction in death, recurrent myocardial infarction, hemorrhagic stroke, and all stroke in patients treated with primary PTCA in a variety of clinical settings; these results have established mechanical reperfusion therapy as the treatment of choice for patients presenting at appropriately equipped facilities and in a timely fashion (9,11–14).

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References

  1. DeW ood MA, Spores J, Notske R, et al. Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction. N Engl J Med 1980; 303: 897–902.

    Article  CAS  Google Scholar 

  2. Davies MJ, Thomas AC. Plaque fissuring-the cause of acute myocardial infarction, sudden ischemic death, and crescendo angina. Br Heart J 1985; 53: 363–373.

    Article  PubMed  CAS  Google Scholar 

  3. The Fibrinolytic Therapy Trialists (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet 1994; 343: 311–322.

    Google Scholar 

  4. Herrmann HC. Triple therapy for acute myocardial infarction: combining fibrinolysis, platelet IIb/IIIa inhibition, and percutaneous coronary intervention. Am J Cardiol 2000; 85: 10C–16C.

    Article  PubMed  CAS  Google Scholar 

  5. The GUSTO Investigators. An international randomized trial comparing four thrombolytic regimens consisting of tissue plasminogen activator, streptokinase, or both for acute myocardial infarction. N Engl J Med 1993; 329: 673–682.

    Article  Google Scholar 

  6. The GUSTO Angiographic Investigators. The effects of tissue plasminogen activator, streptokinase, or both on coronary-artery patency, ventricular function, and survival after acute myocardial infarction. N Engl J Med 1993; 329: 1615–1622.

    Article  Google Scholar 

  7. Meijer A, Verheugt FWA, Werter CPJP, et al. Aspirin versus coumadin in the prevention of reocclusion and recurrent ischemia after successful thrombolysis: a prospective placebo-controlled angiographic study. Circulation 1993; 87: 1524–1530.

    Article  PubMed  CAS  Google Scholar 

  8. Berkowitz SD, Granger CB, Pieper KS, et al, for the GUSTO Investigators. Incidence and predictors of bleeding after contemporary thrombolytic therapy for myocardial infarction. Circulation 1997; 95: 2508–2516.

    Article  PubMed  CAS  Google Scholar 

  9. Grines CL, Brown KF, Marco J, et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. N Engl J Med 1993; 328: 673–679.

    Article  PubMed  CAS  Google Scholar 

  10. Lange RA, Hillis LD. Immediate angioplasty for acute myocardial infarction. N Engl J Med 1993; 328: 726–728.

    Article  PubMed  CAS  Google Scholar 

  11. Gibbons RJ, Holmes DR, Reeder GS, et al. Immediate angioplasty compared with the administration of a thrombolytic agent followed by conservative treatment for myocardial infarction. The Mayo Coronary Care Unite in Catheterization Laboratory groups. N Engl J Med 1993; 328: 685–691.

    Article  PubMed  CAS  Google Scholar 

  12. Zijlstra F, de Boer MJ, Hoorntje JC, et al. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med 1993; 328: 680–684.

    Article  PubMed  CAS  Google Scholar 

  13. The Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO-IIb) Angioplasty Substudy Investigators. A clinical trial comparing coronary angioplasty with tissue plasminogen activator for acute myocardial infarction. N Engl J Med 1997; 336: 1621–1628.

    Article  Google Scholar 

  14. Weaver WD, Simes RJ, Betriu A, et al. Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review. JAMA 1997; 278: 2093–2098.

    Article  PubMed  CAS  Google Scholar 

  15. Serruys PW, de Jaegere P, Kiemeneij F, et al. A comparison of balloon expandable stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med 1994; 331: 489–495.

    Article  PubMed  CAS  Google Scholar 

  16. Fischman DL, Leon MB, Baim DS, et al. A randomized comparison of coronary stent placement and balloon angioplasty in the treatment of coronary artery disease. N Engl J Med 1994; 331: 496–501.

    Article  PubMed  CAS  Google Scholar 

  17. Serruys PW, van Hout B, Bonnier H, et al. Randomised comparison of implantation of heparin-coated stents with balloon angioplasty in selected patients with coronary artery disease (Benestent II). Lancet. 1998 Aug 29; 352 (9129): 673–681.

    Article  CAS  Google Scholar 

  18. Adgey JAA. Overview of the results of clinical trials with glycoprotein IIb/IIIa inhibitors. Am Heart J 1998; 135 (Suppl): S43–S55.

    Article  PubMed  CAS  Google Scholar 

  19. Kong DF, Califf RM, Miller DP, et al. Clinical outcomes of therapeutic agents that block the platelet glycoprotein IIb/IIIa integrin in ischemic heart disease. Circulation 1998;98:2829– 2835.

    Google Scholar 

  20. The Capture Investigators. Randomized placebo-controlled trial of abciximab before and during coronary intervention in refractory unstable angina: the Capture study. Lancet 1997; 349: 1429–1435.

    Article  Google Scholar 

  21. The Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) Study Investigators. Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. N Engl J Med 1998; 338: 1488–1497.

    Article  Google Scholar 

  22. The PURSUIT Trial Investigators. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. N Engl J Med 1998; 339: 436–443.

    Article  Google Scholar 

  23. Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001 Jun 21; 344 (25): 1879–1887.

    Article  CAS  Google Scholar 

  24. Montalescot G, Barragan P, Wittenberg O, et al. for the ADMIRAL Investigators. Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction. N Engl J Med 2001; 344: 1895–1903.

    Article  PubMed  CAS  Google Scholar 

  25. Stone GW, Grines CL, Cox DA, et al. A prospective, randomized trial comparing primary balloon angioplasty with or without abciximab to primary stenting with or without abciximab in acute myocardial infarction—primary endpoint analysis from the CADILLAC Trial. Circulation 2000; 1 8(Suppl 2 ): II - 664.

    Google Scholar 

  26. Stone GW, Grines CL, Browne KF, et al. Implications of recurrent ischemia after reperfusion therapy in acute myocardial infarction: a comparison of thrombolytic therapy and primary coronary angioplasty. J Am Coll Cardiol 1995; 26: 66–72.

    Article  PubMed  CAS  Google Scholar 

  27. O’Neill WW, Brodie BR, Ivanhoe R, et al. Primary coronary angioplasty for acute myocardial infarction (The Primary Angioplasty Registry). Am J Cardiol 1994; 73: 627–634.

    Article  PubMed  Google Scholar 

  28. Fry JA, Grines CL. Does primary stenting in acute myocardial infarction increase mortality? ACC Curr J Rev 2001; 10: 68–71.

    Article  Google Scholar 

  29. Nakae I, Fujita M, Fudo T, et al. Relation between preexistent coronary collateral circulation and the incidence of restenoses after successful primary coronary angioplasty for acute myocardial infarction. J Am Coll Cardiol 1996; 27: 1688–1692.

    Article  PubMed  CAS  Google Scholar 

  30. O’Keefe JH, Rutherford BD, McConahay DR, et al. Early and late results of coronary angioplasty without antecedent thrombolytic therapy for acute myocardial infarction. Am J Cardiol 1989; 64: 1221–1230.

    Article  PubMed  Google Scholar 

  31. Brodie BR, Grines CL, Ivanhoe R, et al. Six-month clinical and angiographic follow-up after direct angioplasty for acute myocardial infarction. Circulation 1994; 90: 156–162.

    Article  PubMed  CAS  Google Scholar 

  32. Nakagawa Y, Iwasaki Y, Kimura T, et al. Serial angiographic follow-up after successful direct angioplasty for acute myocardial infarction. Am J Cardiol 1996; 78: 980–984.

    Article  PubMed  CAS  Google Scholar 

  33. Colombo A, Hall P, Nakamura S, et al. Angiographic follow-up and restenosis results after Palmaz–Schatz intracoronary stenting without anticoagulation. Circulation 1994; 90: I - 124.

    Google Scholar 

  34. Leon MB, Baim DS, Gordon P, et al. Clinical and angiographic results from the Stent Anticoagulation Regina Study (STARS). Circulation 1996; 95: I - 685.

    Google Scholar 

  35. Carrozza JP, Kuntz RE, Levine MJ, et al. Angiographic and clinical outcome of intracoronary stenting: immediate and long-term results form a large single center experience. J Am Coll Cardiol 1992; 20: 328–337.

    Article  PubMed  Google Scholar 

  36. Grines CL, Brodie BR, Griffin JJ, et al. Which primary PTCA patients may benefit from new technologies? Circulation 1995; 92 (Suppl I): I - 146.

    Google Scholar 

  37. Stone GW, Brodie BR, Griffin JJ, et al. A prospective, multicenter study of the safety and feasibility of primary stenting in acute myocardial infarction: in-hospital and 30 day results of the PAMI Stent Pilot Trial. J Am Coll Cardiol 1998; 31: 23–30.

    Article  PubMed  CAS  Google Scholar 

  38. Nakamura S, Colombo A, Gaglione A, et al. Intracoronary ultrasound observations during stent implantation. Circulation 1994 May; 89 (5): 2026–2034.

    Article  PubMed  CAS  Google Scholar 

  39. Schiele F. Intravascular ultrasound guidance for stent implantation. Circulation 2001 May 29; 103 (21): E110–120.

    Article  CAS  Google Scholar 

  40. Morino Y, Honda Y, Okura H, et al. An optimal diagnostic threshold for minimal stent area to predict target lesion revascularization following stent implantation in native coronary lesions. Am J Cardiol 2001 Aug 1; 88 (3): 301–303.

    Article  CAS  Google Scholar 

  41. Kuntz RE, Gibson CM, Nobuyoshi M, Baim DS. Generalized model of restenosis after conventional balloon angioplasty, stenting and directional atherectomy. J Am Coll Cardiol 1993 Jan; 21 (1): 15–25.

    Article  PubMed  CAS  Google Scholar 

  42. Stone GW, Brodie BR, Griffin JJ, et al. Clinical and angiographic follow-up after primary stenting in acute myocardial infarction: The PAMI Stent Pilot Trial. Circulation 1999; 99: 1548–1554.

    Article  PubMed  CAS  Google Scholar 

  43. Antoniucci D, Santoro GM, Bolognese L, et al. A clinical trial comparing primary stenting of the infarct-related artery with optimal primary angioplasty for acute myocardial infarction. Results from the Florence Randomized Elective Stenting in Acute Coronary Occlusions (FRESCO) trial. J Am Coll Cardiol 1998; 31: 1234–1239.

    Article  PubMed  CAS  Google Scholar 

  44. Suryapranata H, van’t Hof A, Hoorntje J, et al. Randomized comparison of coronary stenting with balloon angioplasty in selected patients with acute myocardial infarction. Circulation 1998; 97: 2502–2505.

    Article  PubMed  CAS  Google Scholar 

  45. The GRAMI Investigators. In-hospital and late results of coronary stents versus conventional balloon angioplasty in acute myocardial infarction (GRAMI trial). Am J Cardiol 1998; 81: 1286–1291.

    Article  Google Scholar 

  46. The PASTA trial Investigators. Primary stent implantation is superior to balloon angioplasty in acute myocardial infarction: final results of the primary angioplasty versus stent implantation in acute myocardial infarction (PASTA) trial. Cathet Cardiovasc Intervent 1999; 48: 262–268.

    Article  Google Scholar 

  47. The STENTIM-2 Investigators. A comparison of systematic stenting and conventional balloon angioplasty during primary percutaneous transluminal coronary angioplasty for acute myocardial infarction. J Am Coll Cardiol 2000; 35: 1729–1736.

    Article  Google Scholar 

  48. Stone GW. Stenting in acute myocardial infarction: observational studies and randomized trials—1998. J Inv Cardiol 1998; 10: 16A–26A.

    Google Scholar 

  49. Grines CL, Cox DA, Stone GW, et al. Coronary angioplasty with or without stent implantation for acute myocardial infarction. N Engl J Med 1999; 341: 1949–1956.

    Article  PubMed  CAS  Google Scholar 

  50. Grines CL, Cox DA, Stone GW, et al. Stent PAMI: 12 month results and predictors of mortality. J Am Coll Cardiol 2000; 35 (Suppl A): 402A.

    Google Scholar 

  51. Wakatsuki T, Nakamura M, Tsunoda T, et al. Coronary flow velocity immediately after primary coronary stenting as a predictor of ventricular wall motion recovery in acute myocardial infarction. J Am Coll Cardiol 2000; 35: 1835–1841.

    Article  PubMed  CAS  Google Scholar 

  52. Belli G, Pezzano A, De Biase AM, et al. Adjunctive thrombus aspiration and mechanical protection from distal embolization in primary percutaneous intervention for acute myocardial infarction. Cathet Cardiovasc Interv 2000; 50: 362–370.

    Article  CAS  Google Scholar 

  53. Erbel R, Heusch G. Coronary microembolization—its role in acute coronary syndromes and interventions. Herz 1999; 24: 558–575.

    Article  PubMed  CAS  Google Scholar 

  54. Fuster V, Badimon L, Badimon JJ, Chesebro JH. The pathogenesis of coronary artery disease and the acute coronary syndrome. N Engl J Med 1992;326: 242–250, 310–318.

    Google Scholar 

  55. Coller BS, Scudder LE, Beer J, et al. Monoclonal antibodies to platelet glycoprotein IIb/IIIa as antithrombotic agents. Ann NY Acad Sci 1991, 614: 193–213.

    Article  PubMed  CAS  Google Scholar 

  56. Lincoff AM, Califf RM, Topol EJ. Platelet glycoprotein IIb/IIIa receptor blockade in coronary artery disease. J Am Coll Cardiol 2000; 35: 1103–1115.

    Article  PubMed  CAS  Google Scholar 

  57. The EPISTENT Investigators. Randomised placebo-controlled and balloon-angioplasty-controlled trial to assess safety of coronary stenting with use of platelet glycoprotein IIb/IIIa blockade. Lancet 1998; 352: 87–92.

    Google Scholar 

  58. The EPIC Investigators. Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. N Engl J Med 1994; 330: 956–961.

    Article  Google Scholar 

  59. The EPILOG Investigators. Platelet glycoprotein IIb/IIIa receptor blockade and low dose heparin during percutaneous coronary revascularization. N Engl J Med 1997; 336:1689– 1696.

    Google Scholar 

  60. O’Shea JC, Hafley GE, Greenberg S, et al. Platelet glycoprotein IIb/IIIa integrin blockade with eptifibatide in coronary stent intervention: the ESPRIT trial: a randomized controlled trial. JAMA 2001 May 16; 285 (19): 2468–2473.

    Article  Google Scholar 

  61. The RESTORE Investigators. Effects of platelet glycoprotein IIb/IIIa blockade with tirofiban on adverse cardiac events in patients with unstable angina or acute myocardial infarction undergoing coronary angioplasty. Circulation 1997; 96: 1445–1453.

    Article  Google Scholar 

  62. Gibson CM, Goel M, Cohen DJ, et al. Six-month angiographic and clinical follow-up of patients prospectively randomized to receive either tirofiban or placebo during angioplasty in the RESTORE trial. Randomized Efficacy Study of Tirofiban for Outcomes and Restenosis. J Am Coll Cardiol 1998 Jul; 32 (1): 28–34.

    Article  PubMed  CAS  Google Scholar 

  63. Anderson KM, Califf RM, Stone GW, et al. Long-term mortality benefit with abciximab in patients undergoing percutaneous coronary intervention. J Am Coll Cardiol 2001;37(8):2059– 2065.

    Google Scholar 

  64. Brener SJ, Barr LA, Burchenal JE, et al. Randomized, placebo-controlled trial of platelet glycoprotein IIb/IIIa blockade with primary angioplasty for acute myocardial infarction. Circulation 1998; 98: 734–741.

    Article  PubMed  CAS  Google Scholar 

  65. Schomig A, Kastrati A, Dirschinger J, et al. Coronary stenting plus platelet glycoprotein IIb/IIIa blockade compared with tissue plasminogen activator in acute myocardial infarction. Stent versus Thrombolysis for Occluded Coronary Arteries in Patients with Acute Myocardial Infarction Study Investigators. N Engl J Med 2000 Aug 10; 343 (6): 385–391.

    Article  CAS  Google Scholar 

  66. Neumann FJ, Blasini R, Schmitt C, et al. Effect of glycoprotein IIb/IIIa receptor blockade on recovery of coronary flow and left ventricular function after the placement of coronary-artery stents in acute myocardial infarction. Circulation 1998; 98: 2695–2701.

    Article  PubMed  CAS  Google Scholar 

  67. Neumann FJ, Kastrati A, Schmitt C, et al. Effect of glycoprotein IIb/IIIa receptor blockade with abciximab on clinical and angiographic restenosis rate after the placement of coronary stents following acute myocardial infarction. J Am Coll Cardiol 2000; 35: 915–921.

    Article  PubMed  CAS  Google Scholar 

  68. The ERASER Investigators. Acute platelet inhibition with abciximab does not reduce in-stent restenosis. Circulation 1999; 100: 799–806.

    Article  Google Scholar 

  69. Antman EM, Giugliano RP, Gibson CM, et al. Abciximab facilitates the rate and extent of thrombolysis: results of the Thrombolysis in Myocardial Infarction (TIMI) 14 trial. Circulation 1999; 99: 2729–2732.

    Article  Google Scholar 

  70. Strategies for Patency Enhancement in the Emergency Department (SPEED) Investigators. A trial of abciximab with and without low-dose reteplase for acute myocardial infarction. Circulation 2000; 101: 2788–2794.

    Article  Google Scholar 

  71. Stone GW, Cox D, Garcia E, et al. Normal flow (TIMI-3) before mechanical reperfusion therapy is an independent determinant of survival in acute myocardial infarction: analysis from the primary angioplasty in myocardial infarction trials. Circulation 2001; 104: 636–641.

    Article  PubMed  CAS  Google Scholar 

  72. Ross AM, Coyne KS, Reiner JS, et al. A randomized trial comparing primary angioplasty with a strategy of short-acting thrombolysis and immediate planned rescue angioplasty in acute myocardial infarction: the PACT trial. J Am Coll Cardiol 1999; 34: 1954–1962.

    Article  PubMed  CAS  Google Scholar 

  73. Morrison LJ, Verbeek PR, McDonald AC, et al. Mortality and prehospital thrombolysis for acute myocardial infarction: a meta-analysis. JAMA 2000 May 24–31;283(20):2686–2692.

    Google Scholar 

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Authors
  1. Gregg W. Stone MD
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  2. David E. Kandzari MD
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  3. Cindy L. Grines MD
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Editors and Affiliations

  1. Duke Clinical Research Institute and Division of Cardiology, Duke University Health System, Durham, NC, USA

    James E. Tcheng MD

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Stone, G.W., Kandzari, D.E., Grines, C.L. (2002). Integrating Coronary Stents and Glycoprotein IIb/IIIa Inhibitors into a Mechanical Reperfusion Strategy. In: Tcheng, J.E. (eds) Primary Angioplasty in Acute Myocardial Infarction. Contemporary Cardiology. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-59259-155-8_9

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  • DOI: https://doi.org/10.1007/978-1-59259-155-8_9

  • Publisher Name: Humana Press, Totowa, NJ

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