Intracoronary Versus Intravenous Bolus Abciximab During Primary Percutaneous Coronary Intervention in Patients With Acute ST-Elevation Myocardial Infarction: A Randomised Trial

Study Questions:

What is the safety and efficacy of intracoronary versus intravenous abciximab in patients undergoing primary percutaneous coronary intervention (PCI)?

Methods:

AIDA STEMI was a randomized, open-label, multicenter trial in which patients undergoing primary PCI for ST-segment elevation myocardial infarction (STEMI) were randomly assigned in a 1:1 ratio to intracoronary versus intravenous abciximab bolus (0.25 mg/kg bodyweight) during PCI with a subsequent 12-hour intravenous infusion 0.125 μg/kg/min (maximum 10 μg/min). The primary endpoint was a composite of all-cause mortality, recurrent infarction, or new congestive heart failure (CHF) within 90 days of randomization.

Results:

A total of 2,065 patients were randomly assigned to intracoronary abciximab (n = 1,032) or intravenous abciximab (n = 1,033). There was no difference in the primary composite clinical endpoint at 90 days (7.0% vs. 7.6%; odds ratio, 0.91; 95% confidence interval, 0.64-1.28; p = 0.58). There was no difference in the incidence of death (4.5% vs. 3.6%; 1.24; 0.78-1.97; p = 0.36) or reinfarction (1.8% vs. 1.8%; 1.0; 0.51-1.96; p = 0.99) between the treatment groups. New-onset CHF was less commonly seen in the intracoronary group (2.4% vs. 4.1%; 0.57; 0.33-0.97; p = 0.04). There was no difference in any of the secondary endpoints (time to occurrence of the primary endpoint, early ST-segment resolution, TIMI [Thrombolysis in Myocardial Infarction] flow grade, and enzymatic infarct size) or bleeding complications.

Conclusions:

In patients with STEMI undergoing primary PCI, intracoronary as compared to intravenous abciximab did not result in a difference in the combined endpoint of death, reinfarction, or CHF.

Perspective:

This study clearly demonstrates that there is no advantage to use of intracoronary abciximab over intravenous abciximab except for a possible decrease in CHF. The use of abciximab in patients undergoing primary PCI has declined over the past few years and most patients in the United States are treated with either bivalirudin or eptifibatide. This study did find a reduction in CHF with intracoronary abciximab, although this may be a chance finding since there was no difference in ST resolution or final left ventricular ejection fraction between the two groups. However, there is no downside to intracoronary abciximab (over intravenous use), and in the rare circumstance when abciximab is used, it may be reasonable to administer it directly to the infarct vessel.

Clinical Topics: Anticoagulation Management, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Acute Heart Failure

Keywords: Odds Ratio, Myocardial Infarction, Heart Failure, Peptide Fragments, Stroke Volume, Confidence Intervals, Immunoglobulin Fab Fragments, Infusions, Intravenous, Hirudins, United States, Percutaneous Coronary Intervention


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