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Intracoronary abciximab may improve primary PCI in patients with diabetes, STEMI
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Administration of an intracoronary bolus of abciximab improved outcomes of primary PCI compared with the IV bolus in patients with diabetes and STEMI, according to a study published in the Journal of the American College of Cardiology.
Raffaele Piccolo, MD, from the department of cardiology at Bern University Hospital, Switzerland, and colleagues analyzed patients with or without diabetes admitted for STEMI randomly assigned intracoronary abciximab (ReoPro, Centocor/Eli Lilly) or IV abciximab bolus when receiving primary PCI.
The researchers evaluated data from 2,470 patients pooled from three randomized trials. The primary endpoint was a composite of death and reinfarction. Comprehensive cardiac MRI took place in one study.
Among the cohort, 473 patients (19%) had diabetes. In patients with diabetes, the primary endpoint at 1 year was lower in in those assigned intracoronary abciximab vs. those assigned IV bolus (9.2% vs. 17.6%; HR = 0.49; 95% CI, 0.28-0.83).
The researchers found that assignment to the intracoronary abciximab bolus did not affect the primary endpoint in patients without diabetes (intracoronary, 7.4%; IV, 7.5%; HR = 0.95; 95% CI, 0.68-1.33; P for interaction between diabetes and no diabetes = .034).
Also, in patients with diabetes, intracoronary abciximab was linked to reduced risk for death (5.8% vs. 11.2%; HR = 0.51; 95% CI, 0.26-0.98) as well as definite/probable stent thrombosis (1.3% vs. 4.8%; HR = 0.27; 95% CI, 0.08-0.98) vs. IV abciximab.
In an accompanying editorial, José P.S. Henriques, MD, PhD, and Wouter J. Kikkert, MD, PhD, both from the department of cardiology, Academic Medical Center, University of Amsterdam, wrote, “Local delivery increases the concentration of abciximab within the culprit coronary artery, which might result in local platelet inhibition, displacement of platelet-bound fibrin and resolution of thrombus.
“As a result of insulin resistance, metabolic abnormalities ... and oxidative stress and inflammation, platelet reactivity is strongly increased in patients with diabetes, making them particularly vulnerable to stent thrombosis and recurrent ischemic events,” they wrote. – by James Clark
Disclosure: Piccolo reports receiving a grant from the Veronesi Foundation. Please see the full study for a list of all other researchers’ relevant financial disclosures. Henriques and Kikkert report no relevant financial disclosures.
Perspective
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Sunil V. Rao, MD
The study is interesting, but several caveats should be applied before adopting a practice of routine intracoronary administration of abciximab. No. 1, the study is a meta-analysis that examined a subgroup, not a dedicated randomized trial of patients with diabetes. No. 2, the primary endpoint used in the meta-analysis was not the primary endpoint of any of the included trials. No. 3, only one endpoint, death or reinfarction, met statistical significance in interaction testing. All others were not significant. This study reinforces the importance of potent platelet inhibition in patients with diabetes undergoing primary PCI.
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