INTERVENTIONAL CARDIOLOGY

MULTISTRATEGY: tirofiban and sirolimus in primary PCI

In patients undergoing primary percutaneous coronary intervention, the use of abciximab has been shown to improve ST-segment resolution and to reduce mortality in comparison with placebo. Subsequently, the TARGET (Do Tirofiban and Reo-Pro Give Similar Efficacy) trial, a head-to-head comparison of abciximab against tirofiban, suggested that the former was the more effective of the two drugs, but it was noted that the bolus dose of tirofiban used in the trial was low (10 µg/kg). Therefore the MULTISTRATEGY trial was primarily designed to compare the efficacy of the two drugs when using a more appropriate dose of tirofiban. In addition, as patients with ST-segment elevation myocardial infarction (STEMI) are thought to be at a higher risk for stent thrombosis, patients underwent a second randomisation to either a sirolimus-eluting or non-drug-eluting stent.

An open-label, 2×2 factorial study of 745 patients with STEMI was performed across 16 centres in Italy, Spain and Argentina. The main outcome measure for the drug comparison was the presence of at least 50% ST-segment elevation resolution at 90 minutes after intervention with a prespecified non-inferiority margin of 9% difference. For the stent comparison, the rate of major adverse cardiac events (defined as the composite of death from any cause, reinfarction and clinically driven target-vessel revascularisation within 8 months) was used.

ST-segment resolution occurred in 302/361 patients (83.7%) who had received abciximab and 308/361 (85.3%) who had received a tirofiban infusion (relative risk 1.020; p<0.001 for non-inferiority). Ischaemic and haemorrhagic outcomes were similar in the tirofiban and abciximab groups. At 8 months, major adverse cardiac events occurred in 54 patients (14.5%) with uncoated stents and 29 (7.8%) with sirolimus stents (p = 0.004), predominantly owing to a reduction of revascularisation rates (10.2% vs 3.2%)—the incidence of stent thrombosis was similar in both groups.

The results suggest that using tirofiban in primary …