Correspondence
Comparison of Angioplasty with Stenting in Acute Myocardial Infarction
N Engl J Med 2002; 347:367-368August 1, 2002
- Article
To the Editor:
The results of the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) study, reported by Stone et al. (March 28 issue),1 convincingly validate primary stent implantation as a preferred strategy for the treatment of acute myocardial infarction. However, despite a similar incidence of the primary composite end point (death from any cause, reinfarction, revascularization, or disabling stroke) at six months between patients who received stents with abciximab (10.2 percent) and those who received stents without abciximab (11.5 percent), the study should not be misconstrued as demonstrating that the administration of abciximab during primary stenting is of no benefit. Previous randomized, double-blind studies2,3 have demonstrated approximately a 50 percent reduction in adverse cardiovascular events with abciximab in this setting.
In the CADILLAC trial, the comparison of stenting alone with stenting plus abciximab was not a prespecified hypothesis. Furthermore, the inclusion of patients who had myocardial infarction without ST-segment elevation (12 percent), combined with the exclusion of patients at high risk (those with prior bypass surgery, shock, or lesions not suitable for stenting) resulted in the selection of patients at lower risk than those previously studied. For instance, in the CADILLAC study, 30-day mortality in the group of patients who underwent stenting without receiving abciximab was 2.2 percent, as compared with 4.5 percent in the Intracoronary Stenting and Antithrombotic Regimen 2 (ISAR-2) study,2 6.6 percent in the Abciximab before Direct Angioplasty and Stenting in Myocardial Infarction Regarding Acute and Long-Term Follow-up study (ADMIRAL),3 and 5.8 percent in a recent, large trial of fibrinolysis.4 The 4.7 percent of patients in the stenting-alone group who received abciximab in the CADILLAC study, which was unblinded, also confounds the analysis of this issue. Although the findings suggest that low-risk patients who are pretreated with a thienopyridine had relatively little benefit from abciximab therapy, the weight of prior evidence from nonrandomized and randomized studies of percutaneous coronary intervention, as well as studies of such interventions as rescue treatment, supports the routine use of abciximab in patients with acute myocardial infarction.
4 ReferencesHoward C. Herrmann, M.D.
Hospital of the University of Pennsylvania, Philadelphia, PA 19104
howard.herrmann@uphs. upenn. edu 1
Stone GW ,Grines CL ,Cox DA , et al. Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction. N Engl J Med 2002;346:957-966
Full Text | Web of Science | Medline2
Neumann FJ ,Kastrati A ,Schmitt C , et al. Effect of glycoprotein IIb/IIIa receptor blockade with abciximab on clinical and angiographic restenosis rate after the placement of coronary stents following acute myocardial infarction. J Am Coll Cardiol 2000;35:915-921
CrossRef | Web of Science | Medline3
Montalescot G ,Barragan P ,Wittenberg O , et al. Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction. N Engl J Med 2001;344:1985-1903
Full Text | Web of Science | Medline4
Topol EJ, GUSTO V Investigators
CrossRef | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We thank Dr. Herrmann for his thought-provoking comments. Although the CADILLAC study clearly supports routine stent implantation in patients with acute myocardial infarction, the clinical implications for routine use of abciximab are less certain. Both the ADMIRAL1 and ISAR-22,3 studies were modest in size, and neither trial used loading with a thienopyridine, which is the current standard of care. ISAR-2 allowed prior lytic therapy and enrollment up to 48 hours after the onset of symptoms, and the ADMIRAL study evaluated early administration of abciximab, before angiography. Indeed, the benefits of abciximab in the ADMIRAL study were confined to patients who received the drug in the ambulance or emergency room; this group had a 90 percent reduction in events,2 which is well out of proportion to real-world expectations. Moreover, contrary to Dr. Herrmann's comments, in the CADILLAC study, the cohort of patients without ST-segment elevation was a high-risk population (as shown in Figure 1 of our article), and analysis according to the treatment actually received showed that the rate of adverse events at six months was 10.4 percent among patients who underwent stenting with abciximab, as compared with 10.9 percent among those who underwent stenting without abciximab (P=0.61).
The results of the CADILLAC study are representative of the outcomes that can be expected with current techniques and adjunct pharmacotherapy. We reiterate our conclusions that abciximab, given just before intervention, reduces early recurrent ischemia and subacute thrombosis and facilitates earlier discharge (by approximately 0.5 day), though long-term benefits may not accrue in terms of late clinical events, restenosis, or myocardial recovery. With the principal caveats that patients with shock were excluded and that the trial was statistically underpowered for an assessment of mortality, each physician will need to interpret the relevance of these data to his or her own practice.
3 ReferencesGregg W. Stone, M.D.
Cardiovascular Research Foundation, New York, NY 10022
gstone@crf.org Cindy L. Grines, M.D.
William Beaumont Hospital, Royal Oak, MI 48073James E. Tcheng, M.D.
Duke Clinical Research Institute, Durham, NC 277051
Montalescot G ,Barragan P ,Wittenberg O , et al. Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction. N Engl J Med 2001;344:1895-1903
Full Text | Web of Science | Medline2
Neumann FJ ,Blasini R ,Schmitt C , et al. Effect of glycoprotein IIb/IIIa receptor blockade on recovery of coronary flow and left ventricular function after the placement of coronary-artery stents in acute myocardial infarction. Circulation 1998;98:2695-2701
Web of Science | Medline3
Neumann FJ ,Kastrati A ,Schmitt C , et al. Effect of glycoprotein IIb/IIIa receptor blockade with abciximab on clinical and angiographic restenosis rate after the placement of coronary stents following acute myocardial infarction. J Am Coll Cardiol 2000;35:915-921
CrossRef | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Timm Bauer, Oliver Koeth, Claus Jünger, Tobias Heer, Harm Wienbergen, Anselm Gitt, Jochen Senges, Uwe Zeymer, FOR THE ACUTE CORONARY SYNDROMES RE. (2007) Early percutaneous coronary intervention after fibrinolysis for acute ST elevation myocardial infarction: results of two German multi‐centre registries (ACOS and GOAL). Acute Cardiac Care 9:2, 97-103
CrossRef
