Tirofiban plus sirolimus-eluting stenting reduced death, nonfatal MI, stroke, or restenosis compared to abciximab plus bare-metal stenting (19% vs 50%; HR 0.33; 95% CI 0.18-0.60; P<.001).
RCT (n=175)
Single-blind
randomized
No
Does single high-dose bolus tirofiban plus sirolimus-eluting stenting reduce the composite of death, nonfatal myocardial infarction, stroke, or binary restenosis in patients with STEMI compared to standard-dose abciximab plus bare-metal stenting?
Tirofiban plus sirolimus-eluting stenting significantly reduced the composite of death, MI, stroke, or binary restenosis at 8 months compared to abciximab plus bare-metal stenting in STEMI patients.
Effect estimate: HR 0.33 (95% CI 0.18-0.60)
Absolute Event Rate: 19% vs 50%
p-value: p=<.001
CONTEXT: Bare-metal stenting with abciximab pretreatment is currently considered a reasonable reperfusion strategy for acute ST-segment elevation myocardial infarction (STEMI). Sirolimus-eluting stents significantly reduce the need for target-vessel revascularization (TVR) vs bare-metal stents but substantially increase procedural costs. At current European list prices, the use of tirofiban instead of abciximab would absorb the difference in cost between stenting with sirolimus-eluting vs bare-metal stents. OBJECTIVE: To evaluate the clinical and angiographic impact of single high-dose bolus tirofiban plus sirolimus-eluting stenting vs abciximab plus bare-metal stenting in patients with STEMI. DESIGN, SETTING, AND PATIENTS: Prospective, single-blind, randomized controlled study (Single High Dose Bolus Tirofiban and Sirolimus Eluting Stent vs Abciximab and Bare Metal Stent in Myocardial Infarction STRATEGY) of 175 patients (median age, 63 interquartile range, 55-72 years) presenting to a single referral center in Italy with STEMI or presumed new left bundle-branch block and randomized between March 6, 2003, and April 23, 2004. INTERVENTION: Single high-dose bolus tirofiban regimen plus sirolimus-eluting stenting (n = 87) vs standard-dose abciximab plus bare-metal stenting (n = 88). MAIN OUTCOME MEASURES: The primary end point was a composite of death, nonfatal myocardial infarction, stroke, or binary restenosis at 8 months. Secondary outcomes included freedom, at day 30 and month 8, from major cardiac or cerebrovascular adverse events (composite of death, reinfarction, stroke, and repeat TVR). RESULTS: Cumulatively, 14 of 74 patients (19%; 95% confidence interval CI, 10%-28%) in the tirofiban plus sirolimus-eluting stent group and 37 of 74 patients (50%; 95% CI, 44%-56%) in the abciximab plus bare-metal stent group reached the primary end point (hazard ratio, 0.33; 95% CI, 0.18-0.60; P<.001 P<.001 by Fischer exact test). The cumulative incidence of death, reinfarction, stroke, or TVR was significantly lower in the tirofiban plus sirolimus-eluting stent group (18%) vs the abciximab plus bare-metal stent group (32%) (hazard ratio, 0.53; 95% CI, 0.28-0.92; P = .04), predominantly reflecting a reduction in the need for TVR. Binary restenosis was present in 6 of 67 (9%; 95% CI, 2%-16%) and 24 of 66 (36%; 95% CI, 26%-46%) patients in the tirofiban plus sirolimus-eluting stent and abciximab plus bare-metal stent groups, respectively (P = .002). CONCLUSION: Tirofiban-supported sirolimus-eluting stenting of infarcted arteries holds promise for improving outcomes while limiting health care expenditure in patients with myocardial infarction undergoing primary intervention.
Valgimigli et al. (Tue,) conducted a rct in Acute ST-segment elevation myocardial infarction (STEMI) or presumed new left bundle-branch block (n=175). Tirofiban plus sirolimus-eluting stenting vs. Standard-dose abciximab plus bare-metal stenting was evaluated on Composite of death, nonfatal myocardial infarction, stroke, or binary restenosis at 8 months (HR 0.33, 95% CI 0.18-0.60, p=<.001). Tirofiban plus sirolimus-eluting stenting reduced death, nonfatal MI, stroke, or restenosis compared to abciximab plus bare-metal stenting (19% vs 50%; HR 0.33; 95% CI 0.18-0.60; P<.001).