The SA Journal Diabetes & Vascular Disease Volume 16 No 2 (November 2019)

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SA JOURNAL OF DIABETES & VASCULAR DISEASE RESEARCH ARTICLE
VOLUME 16 NUMBER 2 • NOVEMBER 2019 79
greater reduction of peak hs-TnT, CK-MB levels and ST-segment
resolution compared with IV tirofiban. Both regimens showed similar
results for MACE and major and minor bleeding events during
hospitalisation and after one month of follow up. The risk of bleeding
did not appear to increase with IC administration of tirofiban.
Topol et al. showed that tirofiban in comparison with abciximab
provided more platelet inhibition in diabetic patients during follow
up and helped to prohibit PCI-related ischaemic and thrombotic
complications. 25 The theory is to achieve a high drug concentration
in the culprit epicardial vessel and small vasculature by administering
IC tirofiban during PCI. Compared with IV delivery of tirofiban, IC
delivery was associated with greater procedural success (e.g. TIMI
grade 3 flow).26
Our findings revealed that no reflow and slow flow were
effectively reduced and TIMI flow and MBG had better outcomes
with IC injection of tirofiban. These results were in concordance
with recent studies that proved that IC27 and intralesional delivery
of tirofiban through an aspiration catheter had better myocardial
perfusion and fewer complications, even in complex PCI.28
Loss of endothelium-dependent vasodilation, inflammatory
reaction and platelet-dependent micro-thrombosis are enhanced
by hyperglycaemia, thereby aggravating the perfusion disturbance
of coronary microcirculation.29 The mortality rate was much higher
in patients when MBG decreased to 0 to 1.6,30
To the best of our knowledge, this is the first study to
demonstrate short-term outcomes and safety of IC injection of
high-dose bolus tirofiban plus a maintenance IV, compared with
IV tirofiban in diabetic patients with STEMI. We showed that IC
tirofiban resulted in decreased inflammation in MI, which was
evidenced by a significant reduction in peak CRP level. Previous
studies have reported on the predictive value of CRP in determining
the risk of future cardiovascular events.31,32 Other studies have
documented a post-procedure CRP rise in relation to myonecrosis.33
The efficient inhibition of platelet aggregation by tirofiban led to
inhibition of inflammatory mediators. 34
In spite of no significant differences in bleeding events and
MACE rates during the 30-day follow up after PCI, the IC tirofiban
group showed an improvement in left ventricular function.
However, we need large, long-term, multicentre, randomised trials
to assess whether IC injection of tirofiban at the time of primary PCI
improves clinical outcome in diabetic patients.
The results of this study have certain limitations. We used non-
random selection of patients for IC tirofiban, the patient number
was relatively small, and we evaluated IC tirofiban on STEMI
but did not compare the effects in NSTE-ACS. Despite including
elderly patients in the study, we did not compare major and minor
bleeding incidence and platelet level reduction in different-aged
populations. A possible improvement in clinical outcome could be
observed with longer follow-up periods as left ventricular systolic
function was improved.
Conclusion
IC tirofiban improved coronary blood flow and myocardial tissue
perfusion effectively in diabetic STEMI patients during primary
PCI. Improved LVEF was also observed 30 days post primary PCI.
However, bleeding events and MACE rates showed no significant
difference between the groups.
Table 3. Summary of angiographic characteristics, MACE and bleeding
events in both groups
Group A (IV) Group B (IC)
Parameters (n = 50) (n = 45) χ2/t p-value
TIMI 3 flow after procedure,
n (%) 39 (78) 42 (93) 4.02 0.045*
MBG 3 after procedure 34 (68) 41 (82) 5.34 0.021*
Infarct-related vessel, n (%)
Left anterior descending
artery, n (%) 30 (60) 25 (55) 0.38 0.72
Circumflex artery, n (%) 7 (14) 5 (11.1) 0.072 0.91
Right coronary artery, n (%) 10 (20) 13 (28.8) 0.065 0.92
Triple vessels, n (%) 3 (6) 2 (4.4) 0.00 1.00
Balloon, n (%) 10 (20) 13 (28.8) 0.98
In-hospital MACE, n (%)
In-hospital death, n (%) 2 (4) 1 (2.2) 0.00 1.00
In-hospital stroke, n (%) 0 0 0.00 1.00
In-hospital re-infarction, n (%) 1 (2) 0 0.05 0.993
In-hospital stent thrombosis,
n (%) 1 (2) 0 0.05 0.993
In-hospital TVR, n (%) 0 0 0.00 1.00
1-month MACE, n (%)
1-month death, n (%) 1 (2) 0 1.00
1-month stroke, n (%) 0 0 0.00 1.00
1-month re-infarction, n (%) 1 (2) 1 (2.2) 0.00 1.00
1-month stent thrombosis,
n (%) 1 (2) 1 (2.2) 0.00 1.00
1-month TVR, n (%) 1 (2) 1 (2.2) 0.00 1.00
TIMI major bleeding, n (%) 1 (2) 1 (2.2) 0.00 1.00
TIMI minor bleeding, n (%) 5 (10) 4 (8.8) 0.02 0.95
Thrombocytopenia, n (%) 2 (4) 2 (4.4) 0.00 1.00
TIMI: thrombolysis in myocardial infarction; MBG: myocardial blush grade;
MACE: major adverse cardiac events; TVR: target vessel restenosis.
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