34 / 40
RESEARCH ARTICLE
SA JOURNAL OF DIABETES & VASCULAR DISEASE
76
VOLUME 16 NUMBER 2 • NOVEMBER 2019
Clinical outcome of intracoronary versus intravenous
high-dose bolus administration of tirofiban in diabetic
patients undergoing primary percutaneous coronary
intervention
AHMED A GHONIM, ABDALLA MOSTAFA, AHMED EMARA, ALAA S ALGAZZAR,
MOHAMMED A QUTUB
Correspondence to: Ahmed A Ghonim
Department of Cardiovascular Medicine, Naser Institute for Research and
Therapy, Cairo, Egypt
e-mail:
goodminds@hotmail.comAbdalla Mostafa, Ahmed Emara
Cardiology Department, Menofia University, Almenofia, Egypt
Alaa S Algazzar
Cardiology Department, Ahmed Maher Teaching Hospital,
Cairo, Egypt
Mohammed A Qutub
Division of Cardiology, Department of Medicine, King Abdulaziz University
Hospital, Jeddah Saudi Arabia
Previously published in
Cardiovasc J Afr
2019;
30
: 285–289
S Afr J Diabetes Vasc Dis
2019;
16
: 76–80
Abstract
Background:
Previous trials remain inconsistent regarding
the advantages and hazards related to intracoronary
(IC) compared with intravenous (IV) administration of
thrombolytics. We aimed to evaluate the safety and
effectiveness of IC versus IV tirofiban administration in
diabetic patients (DM) with acute ST-segment elevation
myocardial infarction (STEMI) during primary percutaneous
coronary intervention (PCI)
Methods:
This trial included95patientswhowere randomised
to high-dose bolus plus a maintenance dose of tirofiban
administered either IV or IC. The groups were compared for
the incidence of composite major adverse cardiac events
(MACE) at 30 days. Levels of cardiac markers were recorded
pre- and post-intervention for myocardial perfusion.
Results:
The MACE were not different between the groups,
but post-procedure myocardial blush grade (MBG) 3 and
thrombolysis in myocardial infarction (TIMI) 3 flow were
significant in the IC group (
p
= 0.45, 0.21, respectively),
favouring the IC strategy. Peak values of both creatine
kinase-muscle/brain (CK-MB) and high-sensitivity troponin T
(hs-TnT) were significantly lower in the IC group (155.68 ±
121, 4291 ± 334 ng/dl) versus the IV group (192.4 ± 86, 5342 ±
286 ng/dl) (
p
= 0.021,
p
= 0.035, respectively). The peak value
was significantly lower in the IC group than the IV group in
terms of ST-segment resolution and 30-day left ventricular
ejection fraction (LVEF) (
p
= 0.016 and 0.023, respectively).
Conclusion:
Thirty days post PCI, IC tirofiban was more
efficient in ameliorating blood flow in the coronary arteries
and myocardial tissue perfusion in DM patients after
STEMI despite bleeding events, and MACE rates showed
no significant difference between the groups. The IC group
showed better improvement in LVEF.
Keywords:
diabetes mellitus, STEMI, intracoronary tirofiban,
primary coronary intervention
Impaired glucose metabolism accelerates the risk of arteriosclerosis
and 80% of patients with diabetes mellitus (DM) die from
cardiovascular diseases.
1
Previous trials have demonstrated a
positive correlation between hyperglycaemia and the occurrence
of heart failure, arrhythmia and other complications. Moreover,
hyperglycaemia significantly increased the mortality rate of patients
with diabetes complicated by myocardial infarction (MI).
2
Acute occlusion of the major epicardial coronary artery usually
leads to acute ST-segment elevation myocardial infarction (STEMI).
Successful recanalisation and patency of the occluded vessels with
percutaneous coronary intervention (PCI) or fibrinolytics diminishes
the infarction size, saves the function of the ventricle and decreases
morbidity and mortality rates.
3,4
Several consequences, such as no reflow and slow flow,
associated with more major adverse cardiac events (MACE),
complications and high mortality rates have been observed in
patients with DM complicated by acute MI (AMI) and undergoing
primary PCI.
5,6
Platelet aggregation into the distal microvasculature
or thrombus embolisation immediately after successful intervention
impairs microvascular flow. Administration of glycoprotein IIb/IIIa
inhibitors (GPI) and many catheter-based strategies have been
attempted to overcome this phenomenon.
7,8
American guidelines recommend tirofiban during PCI in patients
with STEMI for high burden of thrombus or patients who received
inadequate loading of P2Y12 inhibitors, and in patients with non-
ST-elevation acute coronary syndrome (NSTE-ACS) and high risk.
9,10
European guidelines recommend tirofiban use in PCI for bailout
situations if there is angiographic evidence of massive thrombus,
slow or no reflow, or thrombotic complications.
11,12
This trial attempted to assess whether intracoronary (IC)
administration of high-dose bolus plus a maintenance-dose
infusion of tirofiban would lead to better efficacy and safety and
enhance clinical outcomes better than the standard intravenous (IV)
bolus-plus-infusion regimen during PCI for diabetic patients with
acute STEMI.