Compared with thrombolytic reperfusion, percutaneous transluminal coronary angioplasty (PTCA) has been found superior for the primary management of acute myocardial infarction in terms of reducing the rates of death, reinfarction, and stroke. However, this initial benefit is compromised by the frequent recurrence of ischemia, reinfarction, and coronary vessel stenosis within several months after PTCA. Two of the most widely employed therapies to improve PTCA outcomes are the placement of intraluminal coronary stents and the use of glycoprotein IIb/IIIa platelet inhibitors.
Stone and colleagues performed a multi-center, prospective, randomized study to determine the best reperfusion strategy in patients with acute myocardial infarction.
A total of 2,082 patients with acute myocardial infarction met the criteria for inclusion in the study. All patients were treated within 12 hours of infarction onset. Exclusion criteria included cardiogenic shock or risk factors for increased bleeding. Before catheterization, each patient received aspirin, a 5,000 U bolus of heparin, an intravenous beta blocker, and either 500 mg of ticlopidine or 300 mg of clopidogrel. Patients were randomized to PTCA alone (518 patients), PTCA plus abciximab (528 patients), stenting alone with MultiLink stent (512 patients), or PTCA with stenting and abciximab therapy (524 patients).
There were no significant differences in the rates of death, reinfarction, or disabling stroke for the four treatment subgroups at 30 days and six months after treatment. However, the need for revascularization varied among the groups. The PTCA-alone group had the highest need for revascularization at 30 days (6 percent) and six months (16.9 percent). When abciximab was added to the initial PTCA, the six-month rate dropped slightly to 14.8 percent. Placement of a stent decreased the rate to 8.9 percent, and the combination of stent and abciximab had the lowest revascularization rate at 5.7 percent.
Hemorrhagic complications during treatment were low (2.7 to 4.5 percent) and did not differ significantly among the groups.
The authors concluded that stent implantation (with or without abciximab therapy) was associated with less need for revascularization after PTCA.