PROSPECT: Major adverse CV events after PCI in patients with ACS attributed to culprit, nonculprit lesions
Stone G. N Engl J Med. 2011;364:226-235.
Data from the PROSPECT trial have indicated that major adverse CV events occurring in patients with acute coronary syndrome who underwent percutaneous coronary intervention were the result of culprit and nonculprit lesions equally.
“The primary purpose of this natural-history study was to provide prospective in vivo confirmation of the hypothesis that ACS arise from atheromas with certain histopathological characteristics, and that these characteristics are not necessarily dependent on the degree of angiographic stenosis at that site,” the researchers wrote. “Although most of the lesions responsible for major adverse CV events during follow-up were angiographically mild, intravascular ultrasonography showed that most had either a small luminal area, a large plaque burden, or both — findings that are consistent with the results of pathological studies.”
The Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) trial featured 697 patients with ACS. After PCI, all patients underwent three-vessel coronary angiography and gray-scale and radiofrequency IVUS (Eagle Eye, In-Vision Gold; Volcano) imaging.
After a median follow-up of 3.4 years, researchers reported a 3-year rate of major adverse CV events of 20.4%, which researchers reported was related to culprit lesions in 12.9% of patients and nonculprit lesions in 11.6%.
Furthermore, nonculprit lesions were predominately mild at baseline. After multivariate analysis, nonculprit lesions that were associated with recurrent events were more likely than those not associated to be characterized by plaque burden of at least 70% (HR=5.03; 95% CI, 2.51-10.11), a minimal luminal area of 4 mm2 or less (HR=3.21; 95% CI, 1.61-6.42), or to be classified by radiofrequency intravascular ultrasonography as thin-cap fibroatheromas (HR=3.35; 95% CI, 1.77-6.36).
Initial Cardiology Today coverage of the PROSPECT trial from Cardiovascular Research Technologies 2010 can be viewed here.
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FINESSE-ANGIO: Pre-cath abciximab before primary PCI linked to higher infarct-related artery patency rates
Prati F. J Am Coll Cardiol Intv. 2010;3:1284-1291.
Pre-cath lab administration of abciximab, both alone and with half-dose reteplase, when preceding primary percutaneous coronary intervention led to higher rates of infarct-related artery patency at baseline coronary angiography vs. standard primary percutaneous coronary intervention, according to data from the FINESSE-ANGIO trial.
Researchers for the Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events-Angiographic (FINESSE-ANGIO) study tested the effects of three different treatments — pre-cath lab administration of half-dose reteplase (Retavase, EKR Therapeutics) plus abciximab (ReoPro, Centocor), abciximab alone or abciximab administered directly before primary PCI — on patency of infarct-related artery during basal coronary angiography. The trial included 637 patients from the FINESSE study.
According to results, patients taking reteplase plus abciximab experienced higher rates of baseline infarct-related artery patency when compared with abciximab alone (76.1% vs. 43.7%; P<.0001) and abciximab taken immediately before PCI procedure (76.1% vs. 32.7%; P<.0001). No significant differences were reported in the post-PCI thrombolysis in MI or the rates of post-PCI TIMI flow grade 3, myocardial blush grade 2/3.
“Primary PCI preceded by pre-catheterization treatment with abciximab alone, and especially with abciximab plus half-dose reteplase, resulted in higher [infarct-related artery] patency rates at baseline coronary angiography compared with standard primary PCI,” the researchers wrote. “Whether clinical benefit correlated with pharmacologically induced or improved pre-PCI myocardial reperfusion may be restricted to higher risk subsets remains to be determined by future prospective studies.”
In an accompanying editorial, Bernard J. Gersh, MB, ChB, DPhil, of the Mayo Clinic, Rochester, Minn.,and Gregg W. Stone, MD,of Columbia University Medical Center, New York, commented on the importance of early treatment.
“For decades, we have appreciated that acute MI is a time-critical phenomenon and that early therapy is crucial for myocardial recovery, especially in the hyperacute phase, when ‘time is myocardium.’ Educating the public to seek treatment at an early stage after symptom onset is likely to reduce mortality to a greater degree than pharmacological facilitation before PCI, although translation of this goal to reality in a community setting is and will continue to be extremely difficult,” Gersh and Stone said.
Disclosure: This study was coordinated in part with research funding from Centocor. Dr. Stone and Dr. Gersh report no relevant financial disclosures.