Coronary stenting plus platelet glycoprotein IIb/IIIa blockade compared with tissue plasminogen activator in acute myocardial infarction

Background Prevention of myocardial damage is the main goal of all reperfus ion therapies in patients with acute myocardial infarction. The relative ef ficacy of various reperfusion strategies is under intensive investigation. We assessed whether coronary stenting combined with the blockade of platele t glycoprotein IIb/IIIa receptors produces a greater degree of myocardial s alvage than fibrinolysis with an accelerated infusion of alteplase, a tissu e plasminogen activator. Methods A total of 140 patients were enrolled in the randomized trial; 71 w ere assigned to receive a stent plus abciximab, and 69 to receive intraveno us alteplase. The primary end point was the degree of myocardial salvage, d etermined by means of serial scintigraphic studies with technetium Tc 99m s estamibi. The secondary end point was a composite of death, reinfarction, a nd stroke within six months after randomization. Results In the group that received a stent plus abciximab, the median size of the final infarct was 14.3 percent of the left ventricle (25th and 75th percentiles, 6.8 and 24.5 percent), as compared with a median of 19.4 perce nt (25th and 75th percentiles, 7.9 and 34.2 percent) in the alteplase group (P=0.02). This difference was due to the larger salvage index (the percent age of the left ventricle that was salvaged, divided by the percentage that was compromised by the initial perfusion defect) in the stent group: 0.57 ( 25th and 75th percentiles, 0.35 and 0.69), as compared with 0.26 (25th an d 75th percentiles, 0.09 and 0.61; P<0.001). The cumulative incidence of de ath, reinfarction, or stroke at six months was lower in the stent group tha n in the alteplase group (8.5 vs. 23.2 percent, P=0.02; relative risk, 0.34 ; 95 percent confidence interval, 0.13 to 0.88). Conclusions In patients with acute myocardial infarction, coronary stenting plus abciximab leads to a greater degree of myocardial salvage and a bette r clinical outcome than does fibrinolysis with a tissue plasminogen activat or. (N Engl J Med 2000; 343: 385-91.) (C) 2000, Massachusetts Medical Socie ty.