Intracoronary Abciximab and Aspiration Thrombectomy in Patients With Large Anterior Myocardial Infarction: The INFUSE-AMI Randomized Trial
What is the impact of intracoronary abciximab, aspiration thrombectomy, or both on infarct size in patients with ST-segment elevation myocardial infarction (STEMI)?
The authors performed a randomized trial of 452 patients presenting within 4 hours of STEMI due to proximal or mid left anterior descending artery occlusion undergoing primary PCI with bivalirudin anticoagulation. Patients were randomized in an open-label, 2 x 2 factorial design to bolus intracoronary abciximab delivered locally at the infarct lesion site versus no abciximab, and to manual aspiration thrombectomy versus no thrombectomy. The primary endpoint of the study was infarct size (percentage of total left ventricular mass) at 30 days assessed by cardiac magnetic resonance imaging in the abciximab versus no abciximab groups (pooled across the aspiration randomization) and the major secondary endpoint was 30-day infarct size in the aspiration versus no aspiration groups (pooled across the abciximab randomization).
Patients randomized to intracoronary abciximab had a significant reduction in 30-day infarct size (median, 15.1% vs. 17.9%; p = 0.03) and a significant reduction in absolute infarct mass (median 18.7 g vs. 24.0 g; p = 0.03), but there was no difference in the abnormal wall motion score (median, 7.0 vs. 8.0; p = 0.08). Patients randomized to aspiration thrombectomy versus no aspiration had no significant difference in infarct size at 30 days (median, 17.0% vs. 17.3%; p = 0.51), absolute infarct mass (median, 20.3 g vs. 21.0 g; p = 0.36), or abnormal wall motion score.
The authors concluded that in patients with anterior wall STEMI, intracoronary abciximab was associated with a reduction in infarct size.
This study demonstrates a slight improvement in myocardial salvage with intracoronary abciximab in patients undergoing primary PCI, although the clinical impact of this remains unclear. The recently published AIDA STEMI study (Thiele H, et al. Lancet 2012;379:923-31) demonstrated a slight reduction in congestive heart failure with intracoronary abciximab, and given the results of these two studies, it would be reasonable to consider an intracoronary route, if abciximab use is contemplated. This study did not find any benefit of aspiration thrombectomy, which is currently used in nearly a third of patients undergoing primary PCI, and invokes the need for large dedicated trials to assess the clinical effectiveness of this common practice.
Clinical Topics: Anticoagulation Management, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Imaging, Magnetic Resonance Imaging
Keywords: Myocardial Infarction, Suction, Platelet Aggregation Inhibitors, Infusion Pumps, Magnetic Resonance Imaging, Angioplasty, Balloon, Coronary, Hirudins, Thrombectomy, Heart Failure, Recombinant Proteins, Salvage Therapy, Peptide Fragments, Cardiovascular Diseases
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