Marden Tabet ING.pmd - Revista Brasileira de Cardiologia Invasiva

More documents

Recommendations

Info

Tebet MA, et al. Primary Angioplasty Using the Radial Access With High Bolus Dose of Tirofiban: a Safe and Effective Technique. Rev Bras Cardiol Invas 2007; 15(3). Figure 1 - Means of access used in elective angioplasties during the period from January 2006 until May 2007. the rest. The success in the elective angioplasties was 98.5%, with ballon angioplasties only in only 5 (1.5%) patients. The 6F caliber introducers were used in 294 patients (97.3%0, in 3 (0.9%) of patients we used 5F introducers and, in 5 (1.5%), 7F caliber introducers. When the right radial approach was not possible, we opted for the left radial artery for the performance of the procedure. In cases on which a temporary pacemaker was necessary, we used the radial access associated to punction of the jugular vein or even to the punction of the femoral vein. This routine access, for the performance of primary angioplasty, was only implanted after a learning curve period of the operators, in accordance with several studies that highlight its importance 23-26 . In our patients group, there was a predominance of AMI of the lower wall, clinically stable in most cases. An eventual major clinical instability, would potencially contribute negatively to the clinical success and would determine a higher necessity for the use of intra-aorta balloon use, which might result in a lower use of the radial access. In spite of it having become an option over ten years ago, for the performance of coronary angioplasty, in our midst, the radial access is still not much used. Araújo and Mangione 27 assesed 53.777 patients submitted to coronary intervention enrolled in the CENIC (Centro Nacional de Intervenciones Vasculares – National Center of Vascular Intervention). Out of these, 48.455 patients underwent elective coronary angioplasty and 5.322 in the course of infarct. The radial access was used only in 10.1% of the elective cases and in 4.6% in the infarct case patients, with the femoral approach used in 87.7% of the elective cases and in 91.7 of the emergencies. It was noticed, that in our country, the radial access is used in selected patients (Male, with only one lesion and who had not undergone previous surgical revascularization). Patients with more serious illness are selected for femoral access. After its introduction by Kiemeneij and Laarman 28 , the benefits of the radial technique have been clearly demonstrated in several studies 7 . Hemorragic complications in the access site are virtually eliminated. After the procedure, walking and hospital discharge are more precocious 8 . The morbidity of the procedure is lower 4 and the patients deffinitely prefer this approach to the transfemoral one 8,29 . Several studies prove the efficacy and safety of the radial approach in patients submitted to primary angioplasty 4, 30, 31 . Saito et al. 31 , randomized 213 patients with AMI within the first 12 hours of the beginning of the symptoms: 77 were treated with the radial approach (RTI) and 72 with the femoral approach (FTI). The success rate of reperfusion and the incidence of major cardiac events (death, non-fatal AMI, repeated revascularization), during hospitalization, were similar (96.1% and 5.2% vs. 97.1% and 8.3%) in the TRI and TFI groups respectively (p = 0.624 and p = 0.444). Philippe et al. 4 also compared the clinical results of the transradial intervention (TRI) and transfemoral intervention (TFI), in primary angioplasty with the use of abciximab. One hundred and nineteen patients were prospectively assessed (TRI n = 64 and TFI n = 55). In that non-randomized study, the free of events overlife was similar for both techniques (97%0 vs. 94.5%; p = 0.19). There were no major hemorragic complications in the TRI group, the opposite to what was found in the TFI group (5.5%, p = 0.03). The hospital stay was also significantly longer in the TFI group 5.9 +/- 2.1 vs. 4.5 +/- 1.2 days; p = 0.05). The glicoprotein inhibitors of the Iib/IIIa are an adjunct therapy of the utmost importance in the treatment of AMI, in spite of conflicting results do not show benefits in the reduction of the mortality rate, when compared to stent implantation 12 . Abciximab has been indicated as the class I drug but, due to its high cost is little used. In comparison to abcximab, tirofiban in the customary doses (bolus of 10 ug/kg and infusion of 0.15 ug/kg/min) were less effective, specially in patients with acute coronary syndrome 14 . The lower event incidence provided by abciximab in that study is due to the lower incidence of periprocedure AMI. Differences were apparent within the next 12 hours, 24 hours at the most, after the procedure. It was found that the extension of the inhibition of the agregation was higher from 15 to 60 minutes from the beginning of the treatment with abciximab. Schneider et al. 16 assessed the dose of the bolus of tirofiban cappable of producing an agregation inhibition higher than 90%, during the first hour of treatment, in patients with accute coronary syndrome, that underwent PCI. Two dossages where tested: bolus of 20 ug/kg and infusion of 0.15 ug/kg/min during 18 to 24 hs or bolus of 25 ug/kg with the same infusion. The second dossage showed an agregation inhibition higher than 90% in the first hour. With the regime used in the TARGET study, the average extention (bolus of 10 ug/kg and infusion of 0.15 ug/kg/min) gives an inhibition of the agregation in response to 20 uM of ADP was 90-94%, in the period of 15 to 60 minutes after the beginning of treatment with abciximab, and 60 – 66%, after tirofiban 17,18 . The interval of 15 to 60 minutes after the beginning of the treatment, is a critical
Tebet MA, et al. Primary Angioplasty Using the Radial Access With High Bolus Dose of Tirofiban: a Safe and Effective Technique. Rev Bras Cardiol Invas 2007; 15(3). period, during which artery lesion takes place due to the balloon and a metal foreign object, potentially thrombogenic (stent), is frequently implanted. In this way, the maximum inhibition of platelet agregation, during this period, would bring about an added benefit. Srinivas et al. 32 assessed the registry of 7.321 patients that underwent primary PCI in the state of New York; 78.5% of which used IGP. The in-hospital mortality was significantly lower in the patients who used IGP (3% vs. 6.2%, p < 0.0001). In 2.837 patients, the type of agent used in primary angioplasty was assessed: 33% received abciximab, 46% eptifibatide or tirofiban and 21% did not receive any medication. The mortality rate was lower in those abciximab and eptifibatide or tirofiban compared to patients who did not receive IGP (3.1% vs. 2.4% vs. 4.7% respectively, p = 0.03). The limitations of the study are its retrospective character and late partial clinical follow up of the population. The number of older patients, in theory more propense to complications with the use of the IGPs, was small. Due to the systematic use of the radial approach in our service, the femoral approach was not possible to compare. CONCLUSION In our Interventionist cardiology service, which uses the radial approach systematically, its use in primary angioplasty is highly efficient and safe, in spite of the use of an aggressive anticoagulation and antiagregation regime. BIBLIOGRAPHIC REFERENCES 1. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361(9351):13-20. 2. Sociedade Brasileira da Cardiologia. III Diretriz sobre tratamento do infarto agudo do miocárdio. Arq Bras Cardiol. 2004;83 (Suppl IV):S1-86. 3. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation. 2004;110(9):e82-292. 4. Philippe F, Larrazet F, Meziane T, Dibie A. Comparison of transradial vs. transfemoral approach in the treatment of acute myocardial infarction with primary angioplasty and abciximab. Catheter Cardiovasc Interv. 2004;61(1):67-73. 5. Lotan C, Hasin Y, Mosseri M, Rozenman Y, Admon D, Nassar H, et al. Transradial approach for coronary angiography and angioplasty. Am J Cardiol. 1995;76(3):164-7. 6. Barbeau GR, Carrier G, Ferland S, Letourneau L, Gleeton O, Lariviere MM. Right transradial approach for coronary procedures: preliminary results. J Invasive Cardiol. 1996;8(suppl): 19D-21D. 7. Kiemeneij F, Laarman GJ. Transradial artery Palmaz-Schatz coronary stent implantation: results of a single-center feasibility study. Am Heart J. 1995;130(1):14-21. 8. Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wicken R. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J Am Coll Cardiol. 1997;29(6):1269-75. 9. Mann T, Cubeddu G, Bowen J, Schneider JE, Arrowood M, Newman WN, et al. Stenting in acute coronary syndromes: a comparison of radial versus femoral access sites. J Am Coll Cardiol. 1998;32(3):572-6. 10. De Luca G, Suryapranata H, Stone GW, Antoniucci D, Tcheng JE, Neumann FJ, et al. Abciximab as adjunctive therapy to reperfusion in acute ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. JAMA. 2005;293(14):1759-65. 11. Montalescot G, Borentain M, Payot L, Collet JP, Thomas D. Early vs. late administration of glycoprotein IIb/IIIa inhibitors in primary percutaneous coronary intervention of acute STsegment elevation myocardial infarction: a meta-analysis. JAMA. 2004;292(3):362-6. 12. Stone GW, Grines CL, Cox DA, Garcia E, Tcheng JE, Griffin JJ, et al. Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction. N Engl J Med. 2002;346(13):957-66. 13. Kandzari DE, Hasselblad V, Tcheng JE, Stone GW, Califf RM, Kastrati A, et al. Improved clinical outcomes with abciximab therapy in acute myocardial infarction: a systematic overview of randomized clinical trials. Am Heart J. 2004;147(3):457-62. 14. Topol EJ, Moliterno DJ, Herrmann HC, Powers ER, Grines CL, Cohen DJ, et al. Comparison of two platelet glycoprotein IIb/IIIa inhibitors, tirofiban and abciximab, for the prevention of ischemic events with percutaneous coronary revascularization. Investigadores do estudo TARGET. N Engl J Med. 2001;334(25):1888-94. 15. Lakkis N, Lakiss N, Bobek J, Farmer J. Platelet inhibition with tirofiban early during percutaneous coronary intervention: dosing revisited. Catheter Cardiovasc Interv. 2002;56(4): 474-7. 16. Schneider D, Herrmann H, Lakkis N, Aguirre F, Wan Y, Aggarwal A, et al. Enhanced early inhibition of platelet aggregation with an increased bolus of tirofiban. Am J Cardiol. 2002;90(12):1421-3. 17. Herrmann HC, Swierkosz TA, Kapoor S, Tardiff DC, DiBattiste PM, Hirshfeld JW, et al. Comparison of degree of platelet inhibition by abciximab versus tirofiban in patients with unstable angina pectoris and non-Q-wave myocardial infarction undergoing percutaneous coronary intervention. Am J Cardiol. 2002;89(11):1293-7. 18. Kabbani SS, Aggarwal A, Terrien EF, DiBattiste PM, Sobel BE, Schneider DJ. Suboptimal early inhibition of platelets by treatment with tirofiban and implications for coronary interventions. Am J Cardiol. 2001;89(5):647-50. 19. Schneider DJ, Herrmann HC, Lakkis N, Aguirre F, Lo MW, Yin KC, et al. Increased concentrations of tirofiban in blood and their correlation with inhibition of platelet aggregation after greater bolus doses of tirofiban. Am J Cardiol. 2003;91(3):334-6. 20. Bolognese L, Falsini G, Liistro F, Angioli P, Ducci K, Taddei T, et al. Randomized comparison of upstream tirofiban versus downstream high bolus dose tirofiban or abciximab on tissuelevel perfusion and troponin release in high-risk acute coronary syndromes treated with percutaneous coronary intreventions. The EVEREST trial. J Am Coll Cardiol. 2006;47 (3):522-8. 21. Valgimigli M, Percoco G, Malagutti P, Campo G, Ferrari F, Barbieri D, et al. Tirofiban and sirolimus-eluting stent vs. abciximab and bare-metal stent for acute myocardial infarction: a randomized trial. JAMA. 2005;293(17):2109-17. 5
Page 1 and 2: Rev Bras Cardiol Invas 2007; 15(3).
Page 3: Tebet MA, et al. Primary Angioplast

Marden Tabet ING.pmd - Revista Brasileira de Cardiologia Invasiva

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?