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Glycoprotein IIb/IIIa inhibitors (GPIs) remain today a cornerstone of treatment in ST-elevation myocardial infarction (STEMI) patients. Among GPIs, Abciximab still remains today the preferable treatment option in STEMI patients undergoing primary angioplasty (PCI). This largely reflects the results of three European studies in which the value of abciximab was shown to accrue overtime over unfractioned heparin alone. Similar to other GPIs available on the market, abciximab displays a potent inhibition of the glycoprotein (GP) IIb/IIIa platelet receptor. Yet, abciximab is unique in that it exerts an irreversible inhibition of the target reception and it concomitantly inhibits other ß3 integrins, such as the vitronectin and the activated MAC-1 receptors. Studies comparing abciximab to eptifibatide are scarce whereas comparisons of abciximab versus tirofiban are largely confined to short-term outcomes.
On the other hand, the long-term safety profile of drug-eluting stent implantation in patients with STEMI remains uncertain as only a limited number of controlled data exists beyond 2 years.
The STRATEGY, TYPHOON and SESAMI trials testing sirolimus-eluting (SES) over bare metal stent implantation in primary PCI reported no safety concern respectively at 5, 4 and 3 year follow-up. Yet, the DEDICATION study which tested a mixture of first and second generation DES showed a higher mortality rate at 3 years in the DES group which was not explained by the difference in myocardial infarction nor stent thrombosis between groups. The PASSION study, in which paclitaxel-eluting stent (PES) was compared to BMS in STEMI patients, recently corroborated the concerns around the use of DES in STEMI by showing a non-significant 49% increase in the rate of recurrent MI and a trend towards almost twice higher rate of definite stent thrombosis in the PES arm through five years.
To investigate whether the use of tirofiban, given at high-dose bolus, leads to comparable and endurable clinical outcomes over abciximab as well as the long-term safety/efficacy profile of SES over BMS in STEMI patients, the 3-year results of the MULTIcentre evaluation of Single high-dose bolus TiRofiban versus Abciximab with sirolimus eluting sTEnt or Bare Metal Stent in Acute Myocardial Infarction studY (MULTISTRATEGY) are reported here.
Complete data at 3 years was available for 736 patients (99%). All-cause mortality was 6.7% in the tirofiban and 7.8% in the abciximab (P=0.56) and 7.5% in the BMS vs 7.0% in the SES groups, P=0.79. The composite of all-cause death or MI was identical at 12.9% in tirofiban and abciximab groups, P=0.99 and it occurred in 13.2% in the BMS vs. 12.6% in the SES groups (P=0.83). The need for reintervention remained more than twice as common with BMS (13.7%; versus 6.2%, HR, 2.29; 95%CI, 1.4 to 3.7; P=0.0006). The cumulative rate of stent thrombosis (ST) did not differ.
The 3-year follow-up of MULTISTRATEGY demonstrated comparable outcomes with HDB Tirofiban or abciximab and a sustained efficacy of SES to reduce reintervention with no difference in death, repeat MI or ST.
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