Effectiveness of Early Coronary
Angioplasty and
Abciximab
for Failed
Thrombolysis (
Reteplase
or
Alteplase
)
During Acute Myocardial Infarction
(Results from the GUSTO-III Trial)
Julie M. Miller,
MD
, Richard Smalling,
MD
, E. Magnus Ohman,
MD
,
Christoph Bode,
MD
, Amadeo Betriu,
MD
, Neal S. Kleiman,
MD
,
Jonathan S. Schildcrout,
MS
, Eugenia Bastos,
MS
, Eric J. Topol,
MD
,
Robert M. Califf,
MD
, for the GUSTO-III Investigators
We evaluated the effects of abciximab treatment during
early angioplasty after clinically failed thrombolysis for
acute myocardial infarction. In the Global Use of Strat-
egies To Open occluded coronary arteries (GUSTO-III)
trial of reteplase versus alteplase for acute infarction
(n ؍ 15,059), 392 patients underwent angioplasty a
median of 3.5 hours after thrombolysis and had com-
plete procedural data. We compared 30-day mortality
and in-hospital outcomes between patients who re-
ceived abciximab (n ؍ 83) and those who did not (n ؍
309), and (among patients given abciximab) between
those randomized to alteplase versus reteplase. Patients
given abciximab had anterior infarction less often, but
were more often in Killip classes III or IV. The 30-day
mortality rate tended to be lower with abciximab (3.6%
vs 9.7%, p ؍ 0.076), more so after adjustment for
baseline differences (p ؍ 0.042). The composite of
death, stroke, or reinfarction did not differ significantly
with abciximab treatment (12% vs 14%, p ؍ 0.7), but it
occurred less often among abciximab-treated patients
who had been randomized to reteplase (n ؍ 55) versus
alteplase (n ؍ 28) (7% vs 21%, p ؍ 0.08). Severe
bleeding was increased among abciximab-treated pa-
tients (3.6% vs 1.0%, p ؍ 0.08), despite less heparin
use. No intracranial hemorrhages occurred with abcix-
imab. The use of abciximab for early angioplasty after
clinically failed thrombolysis resulted in trends toward
lower 30-day mortality and increased bleeding.
ᮊ1999 by Excerpta Medica, Inc.
(Am J Cardiol 1999;84:779 –784)
E
arly percutaneous transluminal coronary angio-
plasty (PTCA) after clinically failed thrombolysis
improves acute infarct-artery patency and is success-
ful in up to 90% of cases.
1
A small, randomized trial
of patients with anterior wall acute myocardial infarc-
tion (AMI) has also suggested that successful rescue
PTCA may salvage myocardium and reduce later isch-
emic events and mortality.
2
Despite these potential
benefits, early PTCA carries a higher risk of reocclu-
sion (up to 30%)
3
and, if unsuccessful, a high mortal-
ity rate.
1,4
Potent platelet glycoprotein IIb/IIIa recep-
tor blockade during emergency PTCA has been shown
to reduce ischemic events (death, AMI, and repeat
coronary revascularization) with only a moderate in-
crease in bleeding risk.
5–7
Abciximab used during primary PTCA reduces
death, reinfarction, or urgent repeat target-vessel re-
vascularization by 48% at 30 days.
7
The risks and
benefits of this treatment during early PTCA after
full-dose thrombolysis, however, are uncertain. We
assessed acute and 30-day outcomes with abciximab
use during early PTCA after reteplase or alteplase
treatment of AMI.
METHODS
Study design:
This was a prospectively designed
analysis of a subgroup of patients in the Global Use of
Strategies To Open occluded coronary arteries (GUS-
TO-III) trial who underwent early PTCA.
8
In brief,
patients of any age who had ST-segment elevation Ն1
mm in 2 consecutive limb leads or Ն2mmin2
precordial leads, or bundle branch block Ͻ6 hours
after symptom onset were eligible. Patients were ex-
cluded from GUSTO-III for factors related to bleeding
or stroke risk. Patients were randomized in a 2:1 ratio
to reteplase (2 10-MU boluses, 30 minutes apart) or
alteplase (as given in GUSTO-I),
9
and all received
aspirin and weight-adjusted heparin bolus and infu-
sion. Other medications or procedures were continued
and/or discontinued at the investigators’ discretion.
The characteristics and outcomes of patients who
underwent PTCA within 24 hours after thrombolysis
began were prospectively collected. Detailed proce-
From the Duke Clinical Research Institute, Durham, North Carolina;
Hermann Hospital, Houston, Texas; University of Heidelberg, Heidel-
berg, Germany; Hospital Clinic I, Barcelona, Spain; Methodist Hos-
pital, Houston, Texas; and the Cleveland Clinic Foundation, Cleve-
land, Ohio. The GUSTO-III trial was funded by a grant from Boehring-
er-Mannheim Therapeutics, Mannheim, Germany, and Gaithersburg,
Maryland. Manuscript received March 8, 1999; revised manuscript
received and accepted April 30, 1999.
Address for reprints: E. Magnus Ohman, MD, Duke Clinical Re-
search Institute, P.O. Box 17969, Durham, North Carolina 27715.
E-mail: ohman001@mc.duke.edu.
779
©1999 by Excerpta Medica, Inc. All rights reserved. 0002-9149/99/$–see front matter
The American Journal of Cardiology Vol. 84 October 1, 1999 PII S0002-9149(99)00437-3