Immediate transfer for PCI after fibrinolysis plus abciximab improves outcome in CARESS-in-AMI trial

February 15, 2008 By Vijayalakshmi Kunadian MBBS MD MRCP [mailto:vkunadian@perfuse.org]

London: Researchers from Europe demonstrate improved outcomes among patients transferred immediately for PCI after pretreatment with half dose fibrinolytic and abciximab compared to rescue PCI following acute myocardial infarction.

While primary percutaneous coronary intervention (PCI) is the optimal treatment for patients presenting with acute myocardial infarction (MI), in a number of countries it is not feasible to deliver a primary PCI service to all patients due to logistical problems associated with transfer of patients to a PCI centre. A previous study using a facilitated approach (improve PCI outcomes using a full dose fibrinolytic prior to PCI) had not proved beneficial in improving outcomes and was associated with a significant increase in stroke rates.

Investigators from France, Italy and Poland tested the hypothesis that pretreatment with half does fibrinolytic plus abciximab and immediate transfer of acute MI patients who present to a non-PCI centre would be beneficial compared to a strategy of rescue PCI in the CARESS-in-AMI trial (Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction). The results of this multicenter, randomized study are published in the latest issue of the Lancet.

A total of 600 patients from the three countries who presented with ST segment elevation myocardial infarction were included in the study. Patients with new left bundle branch block, previous MI, Killip class >2 and left ventricular ejection fraction ≤35% were included in the study. All patients were pretreated with half dose reteplase, abciximab, heparin and aspirin. Subsequently they were randomized to (1) immediate transfer to a PCI center for angiography ± PCI (group 1) and (2) transfer only when there was evidence of failure to reperfuse [persistent ST-segment elevation and clinical deterioration] (group 2).

The primary endpoints for this study consisted of death, reinfarction and refractory ischemia at 30 days.

In total, 299 patients were randomised to group 1. Of these, 289 (97%) patients underwent angiography and 255 (85.6%) patients underwent PCI. In group 2, 91(30.3%) patients underwent rescue PCI. The primary endpoint occurred in 4.4% of patients in group 1 compared to 10.7% in group 2, p=0.004. Major bleeding occurred in 3.4% of patients in group 1 compared to 2.3% in group 2, p=0.47. There was no difference in the incidence of stroke between the two groups (p=0.50).

In centers with no primary PCI facility, the strategy of pretreatment with half dose fibrinolytic plus abciximab and immediate transfer of patients to a PCI center seem to be beneficial compared to referring patients for PCI following failed fibrinolysis. This study suggests that the pretreatment and transfer strategy was not associated with increased bleeding and stroke rates.