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  • Efficacy and safety of a routine early invasive strategy after fibrinolysis stratified by glycoprotein IIb/IIIa inhibitor use during percutaneous coronary intervention: a pre-specified subgroup analysis of the TRANSFER-AMI randomised controlled trial

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Coronary artery disease
Original article
Efficacy and safety of a routine early invasive strategy after fibrinolysis stratified by glycoprotein IIb/IIIa inhibitor use during percutaneous coronary intervention: a pre-specified subgroup analysis of the TRANSFER-AMI randomised controlled trial
  1. Juan J Russo1,
  2. Shaun G Goodman1,2,
  3. Warren J Cantor3,
  4. David Fitchett1,
  5. Michael Heffernan4,
  6. Bjug Borgundvaag5,
  7. John Ducas6,
  8. Eric A Cohen7,
  9. Vladimír Džavík8,
  10. Shamir R Mehta9,
  11. Christopher E Buller1,
  12. Andrew T Yan1,
  13. for the TRANSFER-AMI investigators
  1. 1Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
  2. 2Canadian Heart Research Centre, Toronto, Ontario, Canada
  3. 3Southlake Regional Health Centre, Newmarket, Ontario, Canada
  4. 4Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada
  5. 5Schwartz/Reisman Emergency Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
  6. 6St. Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
  7. 7Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
  8. 8University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
  9. 9Population Health Research Institute, Hamilton, Ontario and Hamilton General Hospital, Hamilton, Ontario, Canada
  1. Correspondence to Dr Andrew T Yan, Division of Cardiology, St Michael's Hospital, 30 Bond Street, Donnelly 6-030, Toronto, Ontario, Canada M5B 1W8; yana{at}smh.ca

Abstract

Objective We evaluated the efficacy and safety of an early invasive strategy post-fibrinolysis in relation to glycoprotein (GP) IIb/IIIa inhibitor use.

Methods The Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) randomised 1059 ST elevation myocardial infarction patients to an early invasive strategy or standard therapy post-fibrinolysis. The primary end point was the composite of death, reinfarction, recurrent ischaemia, new or worsening heart failure, or cardiogenic shock at 30 days. In this pre-specified analysis, we examined efficacy and safety outcomes of an early invasive strategy after stratification by GPIIb/IIIa inhibitor use, which was permitted during percutaneous coronary intervention (PCI) at the discretion of the treating physician.

Results A total of 695 patients (65.6%) received GPIIb/IIIa inhibitors. There was significant heterogeneity (p<0.001) in the efficacy of an early invasive strategy compared to standard therapy, between the strata with GPIIb/IIIa inhibitor use (primary end point 9.6% vs 22.3% respectively, p<0.001) and without GPIIb/IIIa inhibitor use (primary end point 14.8% vs 10.4% respectively, p=0.21). Patients who received GPIIb/IIIa inhibitors had lower Global Registry of Acute Coronary Events (GRACE) risk scores compared to those without GPIIb/IIIa inhibitor use (median 121 vs 130, p<0.001). After adjusting for the interaction between GRACE risk score and treatment assignment, the heterogeneity in the efficacy of an early invasive strategy with respect to GPIIb/IIIa inhibitor use was no longer significant (p interaction=0.08).

Conclusions The apparent difference in the efficacy of an early invasive strategy between GPIIb/IIIa inhibitor strata likely reflects an association between GPIIb/IIIa inhibitor use and baseline risk. GPIIb/IIIa inhibitor use during PCI at the discretion of the treating physician does not appear to modulate the efficacy of an early invasive strategy post-fibrinolysis.

https://doi.org/10.1136/heartjnl-2013-305231

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