Direct and Rescue PTCA

1
ANTITHROMBOTICS IN PRIMARY PCI
Freek W.A. Verheugt
Department of Cardiology, Heartcenter
University Medical Center, Nijmegen, The
Netherlands
2
ANTITHROMBOTICS IN PRIMARY PCI
1st generation
aspirin (ISIS-2)
heparin (HEAP)
2nd generation
half-dose lytic (PACT)
half-dose lytic abciximab (GUSTO-V, ASSENT-3)
3nd generation
GP IIb/IIIa receptor blockers(GRAPE, AMIRAL,
CADILLAC)
clopidogrel (CLARITY-TIMI-28)
3
(No Transcript)
4
Differential Binding to Xa and IIaLMWHs versus
UFH
LMWHs
UFH
5
5
Xa
Xa
AT 3
AT 3
lt13 units
gt13 units
Complex with AT 3 and Xa
Complex with AT 3 and Xa
5
5
IIa
IIa
AT 3
AT 3
gt13 units
lt13 units
Complex with ATIII AND thrombin
Complex with ATIII but NOT to thrombin
Hirsh J, et al. Chest 200111964S-94S.
5
ASPIRIN AND HEPARIN PRIOR TO PRIMARY PCI
nil
p
aspirin heparin
(n860)
(n842)
age (yr)
59
61
0.01
time to treatment gt 3h
54
51
TIMI-2 and 3 pre-PCI
31
21
0.001
30d death
3.0
2.9
LVEF anterior MI ()
43
37
0.03
50
47
LVEF non-anterior MI
0.22
cum LDH anterior MI
1,421
1,691
0.17
705
0.16
cum LDH non-anterior MI
849
Zijlstra F. J Am Coll Cardiol 2002391733-1737
6
Ross AM. J Am Coll Cardiol 1999341954-1962
7
GUSTO V. JAMA 20022882130-2135
8
FACILITATED PCI
9
Van den Merkhof LFM. JACC 1999331528-1532
10
ADMIRAL
placebo
abciximab
p
(n151)
(n149)
TIMI-3 flow pre-PTCA
10
21
.01
TIMI-3 flow 24h post-PTCA
78
86
.05
LVEF pre-PTCA
39
41
LVEF 24h post-PTCA
51
54
30 days death
4.7
3.3
30 days death/reMI/rev.
20
11
.03
transfused (gt2U) bleeds
2.6
4.0
Montalescot G. N Engl J Med 20013441895-1903
11
CADILLAC
balloon
balloon
stent
stent
placebo
abciximab
abciximab
placebo
(n518)
(n528)
(n524)
(n512)
stent
18.1
14.0
97.7
98.0
7.3
99.1
99.4
4.7
abciximab
94.7
96.1
96.1
94.5
TIMI-3 (core)
30 d MACE
8.3
4.8
5.7
4.4

6 mos MACE
20.0
16.5
11.5
10.2
7 mos reocclusion
12.2
10.4
6.5
5.2
primary endpoint stent vs balloon p 0.004
Stone GW. NEJM 2002346957-966
12
(n3,366)
Topol EJ. JACC 2003421886-1887
13
(n3,366)
Topol EJ. JACC 2003421886-1887
Topol EJ. JACC 2003421886-1887
14
TIGER-PA. Circulation 20031071497-1501
n100
15
Preventing RethrombosisConclusions
Primary PCI
aspirin/heparin
abciximab
clopidogrel
16
APRICOT-2
Brouwer MA. Circulation 2002106659-665
17
CADILLAC
balloon
balloon
stent
stent
placebo
abciximab
abciximab
placebo
(n518)
(n528)
(n524)
(n512)
stent
18.1
14.0
97.7
98.0
7.3
99.1
99.4
4.7
abciximab
94.7
96.1
96.1
94.5
TIMI-3 (core)
30 d MACE
8.3
4.8
5.7
4.4

6 mos MACE
20.0
16.5
11.5
10.2
7 mos reocclusion
12.2
10.4
6.5
5.2
primary endpoint stent vs balloon p 0.004
Stone GW. NEJM 2002346957-966