Background and aim: This systematic review with meta-analysis sought to compare the efficacy and safety of intracoronary (IC) vs. intravenous (IV) administration of glycoprotein (GP) IIb/IIIa receptor inhibitors on clinical outcomes following per­cutaneous coronary intervention in patients with acute coronary syndromes (ST-segment elevation myocardial infarction or non-ST-segment-elevation acute coronary syndrome). Methods: Medline, Embase, Elsevier, and Sciences online databases as well as Google Scholar literature were used to select appropriate studies with randomised controlled design. The primary end-points were mortality and target vessel revascularisation (TVR), whereas the secondary end points were incidence of thrombolysis in myocardial infarction score 3 flow (TIMI 3 flow means complete perfusion in distal coronary artery bed), re-myocardial infarction (re-MI), major bleeding, stent thrombosis left ventricular ejection fraction (LVEF), and heart failure (HF). The literature search of all major databases retrieved 1006 stud­ies. After screening, a total of 18 trials (5812 patients) were identified with reported outcomes. Results: Pooled analysis showed IC administration of GP IIb/IIIa receptor inhibitors can significantly increase LVEF (WMD 4.97; 95% CI 3.34–6.60; p = 0.000) and the incidence of TIMI 3 flow (OR of 0.77; 95% CI 0.64–0.92; p = 0.005), and significantly decrease in incidence of HF (OR of 1.927; 95% CI 1.189–3.124; p = 0.008). Incidences of TVR, re-MI, major bleeding, stent thrombosis, and mortality showed no significant differences between the IC and IV groups. Conclusions: Overall, the most appropriate route of administration of GP IIb/IIIa inhibitors for patients with acute coronary syndromes appeared to be an IC injection that could increase LVEF and TIMI 3 flow and decrease the incidence of HF. Furthermore, the IC administration was not associated with increased adverse event rates when compared to IV injection.

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Appropriate bolus administration of glycoprotein IIb/IIIa inhibitors for patients with acute coronary syndromes undergoing percutaneous coronary intervention: intracoronary or intravenous? A comprehensive and updated meta-analysis and systematic review

The aim of this study was to investigate the effect of different routes of tirofiban injection on the function of the left ventricle and the prognosis of patients with myocardial infarction (MI) treated with percutaneous coronary intervention (PCI). Ninety-five patients with MI treated with PCI were divided into two groups [coronary (n=49) and intravenous (n=46)] according to the injection route. A comparison of the left ventricular function and prognosis was made between the two groups following PCI. The success rate of PCI in the coronary group was 97.96%, which was higher than that in the intravenous group (P<0.05). No significant differences were identified in the platelet count (PLT) and platelet aggregation rate (PAR) between the two groups prior to the tirofiban injection. Following the tirofiban injection, the PLT decreased markedly in both groups, with no significant differences between them. The PAR also decreased significantly in the two groups; however, the value in the coronary group was lower than that in the intravenous group (P<0.05). The improvements in the thrombolysis in MI grades, left ventricular ejection fraction and left ventricular diastolic function were greater in the coronary group than those in the intravenous group (P<0.05). All patients received follow-up for 30 days and the incidence of bleeding in the coronary group was lower than that in the intravenous group (P<0.05). No significant differences were recorded in the recurrence rates of MI, arrhythmia, myocardial ischemia, thrombocytopenia and mortality between the two groups. In conclusion, the administration of tirofiban into the coronary artery could effectively improve the blood flow, left ventricular function and prognosis of patients with MI treated with PCI.

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Effects of different routes of tirofiban injection on the left ventricular function and prognosis of patients with myocardial infarction treated with percutaneous coronary intervention.

We present a case of a 51-year-old male with acute anterior myocardial infarction, who was transferred to our hospital under mechanical ventilation, after resuscitation due to cardiopulmonary arrest. The patient underwent urgent coronary angiography, which showed total thrombotic occlusion of the proximal segment of the left anterior descending (LAD) coronary artery disease. During primary percutaneous coronary intervention (PPCI), thrombosis extended into the left main coronary artery (LMCA), the LAD and the left circumflex artery (LCx) coronary arteries, causing severe hemodynamic compromise. This devastating complication was successfully managed with intracoronary administration of antithrombotic and antiplatelet drugs, as well as thrombus aspiration. We herein discuss the possible mechanisms of this complication and highlight its prevention and treatment.

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Thrombosis of Left Coronary Artery During Primary Percutaneous Coronary Intervention

Background: In patients with acute myocardial infarction or unstable angina undergoing coronary angioplasty, abciximab reduces major adverse cardiac events (MACE). Most clinical trials have studied mainly intravenous administration. Intracoronary (IC) bolus application of abciximab causes very high local drug concentrations and may be more effective in reducing acute and sub-acute stent thrombosis (ST). We studied whether IC bolus administration of abciximab is associated with a reduced ST and target vessels revascularization (TVR); therefore, less MACE rate compared with the standard intravenous IV bolus and infusion application. Materials and Methods: This was a single-center observational study conducted between June 2007 and 2009. We studied a total of 447 patients admitted with either acute coronary intervention (PCI) and stenting. Patients with bleeding disorder, recent major surgery and high blood pressure were excluded. Patients were divided into two groups: Group I (n = 199) patient received IC bolus of abciximab (reopro) 0.25 μg/kg during the PCI in cath lab. Group II (n = 248) received the standard dose of reopro-a bolus intravenous 0.25 μg/kg and maintenance dose of 0.125 μg/kg over 12 h. Results: There were no differences between the groups with regard to diabetes mellitus, group I (56%) vs. group II (58%), P = 0.613; ACS, group I (38%) vs. group II (44%), P = 0.175; Dietthylstilbestrol Drug eluted stent (DES) in group I (66.5%) vs. (57.6%) group II, P = 0.056; Bare Metal Stent (BMS) in group I (33%) vs. (40.7%) group II, P=0.093; target vessel revascularization (TRV) was seen in 9 patients (4%) in group I vs. 16 patients (6%) in group II. ST elevation was seen in 4 patients (2%) in group I vs. 7 patients (2.8%) in group II, all presented with STEMI. Conclusion: In this study, there was a trend toward less ST and TVR in patients who received IC reopro vs. intravenous route both in ACS and stable CAD. The percentage of DM was high in both groups (56%), especially in Saudi patients. In-stent restenosis (ISR) was less in group I than in group II, this was mainly associated with BMS usage. The percentage of BMS was more than 30% in both groups, either due to STEMI cases or large vessel size. Randomized controlled trials are warranted to further assess IC application of abciximab in reducing ST.

El Harif Zain

Papers

Intracoronary Reopro during Percutaneous Coronary Intervention in Acute and Stable Patient can Influence Stent Thrombosis Formation (IRPASST) Study.