Upstream tirofiban reduces reperfusion cardiac arrhythmias in patients of acute ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Abstract

“Open the artery in time” has become the dogma in treating ST-elevation myocardial infarction (STEMI) since the 1990s. It has been a consensus that the more patent the infarct-related artery (IRA), the better the clinical outcomes [ 1 Simes R.J. Topol E.J. Holmes Jr., D.R. et al. Link between the angiographic substudy and mortality outcomes in a large randomized trial of myocardial reperfusion. Importance of early and complete infarct artery reperfusion. GUSTO-I Investigators. Circulation. 1995; 91: 1923-1928 Crossref PubMed Scopus (463) Google Scholar , 2 Anderson J.L. Karagounis L.A. Califf R.M. Meta-analysis of five reported studies on the relation of early coronary patency grades with mortality and outcomes after acute myocardial infarction. Am J Cardiol. 1996; 78: 1-8 Abstract Full Text PDF PubMed Scopus (160) Google Scholar ]. In addition, the strategies of reperfusion, referring to intravenous thrombolytics and primary percutaneous coronary interventions (pPCI), have been proved to differ among themselves in acute success of reperfusion and long-term outcomes. The pPCI is better in restoring the coronary blood flow and renders less complications than thrombolytic therapy [ 3 Zijlstra F. de Boer M.J. Hoorntje J.C.A. Reiffers S. Reiber J.H. Suryapranata H. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med. 1993; 328: 680-684 Crossref PubMed Scopus (1177) Google Scholar , 4 Zeymer U. Schroder R. Machnig T. Neuhaus K.L. Primary percutaneous transluminal coronary angioplasty accelerates early myocardial reperfusion compared to thrombolytic therapy in patients with acute myocardial infarction. Am Heart J. 2003; 146: 686-691 Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar ]. As the platelet plays the central role in triggering the acute thrombotic mechanism in STEMI, the complete inhibition of the platelet function, from adhesion, activation to aggregation, has been the focus of current optimal anti-platelet therapy. The standard dual anti-platelet therapy (DAT), consisting of aspirin and clopidogrel, exerts its function to counteract the platelet activation. The inadequacy and negligence to inhibiting platelet aggregation at the time of pPCI were proved to result in more major adverse cardiovascular events (MACE), especially in patients of clopidogrel resistance [ [5] Matetzky S. Shenkman B. Guetta V. et al. Clopidogrel resistance is associated with increased risk of recurrent atherothrombotic events in patients with acute myocardial infarction. Circulation. 2004; 109: 3171-3175 Crossref PubMed Scopus (1282) Google Scholar ]. It is also said “the lower the platelet reactivity, the less the myocardial necrosis and the better the clinical outcomes [ [6] Campo G. Valgimigli M. Gemmati D. et al. Value of platelet reactivity in predicting response to treatment and clinical outcome in patients undergoing primary coronary intervention. Insights into the STRATEGY Study. J Am Coll Cardiol. 2006; 48: 2178-2185 Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar ].” In order to further block the platelet aggregation, adding a glycoprotein IIb/IIIa (GP IIb/IIIa) antagonist, thus formulating the triple anti-platelet therapy, has been recommended for high risk non-ST-elevation acute coronary syndromes (NSTEACS) [ [7] Bassand J.P. Hamm C.W. Ardissino D. et al. Task force for diagnosis and treatment of non ST elevation acute coronary syndromes. Eur Heart J. 2007; 28: 1598-1660 Crossref PubMed Scopus (49) Google Scholar ]. GP IIb/IIIa antagonist, especially tirofiban, could be adopted as one of the background therapy in dealing with NSTEACS [ [8] Hsin H.T. Li A.H. Yeih D.F. et al. Two-year follow-up of tirofiban-based management of non-ST-elevation acute coronary syndrome — a single center study. Acta Cardiol Sin. 2010; 26: 19-27 Google Scholar ]. On the other hand, peri-PCI abciximab has been demonstrated to significantly improve reperfusion in the infarct region and clinical outcomes of patients with STEMI undergoing pPCI, which has been regarded as class IIa recommendation since 2004 [ 9 Van de Werf F. Ardissino D. Betriu A. et al. Management of acute myocardial infarction in patients presenting with ST-segment elevation. The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J. 2003; 24: 28-66 Crossref PubMed Scopus (1491) Google Scholar , 10 Antman E.M. Anbe D.T. Armstrong P.W. et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004; 44: E1-E211 Abstract Full Text PDF PubMed Google Scholar ]. However, the role of tirofiban is rather obscure. The efficacy and timing to administer tirofiban in STEMI are still on debate.