Combination reperfusion therapy with eptifibatide and reduced-dose tenecteplase for ST-elevation myocardial infarction

• Published in: Journal of the American College of Cardiology Vol. 41; no. 8; pp. 1251 - 1260
• Main Authors: Giugliano, Robert P., Roe, Matthew T., Woodlief, Lynn H., Harrington, Robert A., Hannan, Karen L., Califf, Robert M., Gibson, C.Michael, Zeymer, Uwe, Van de Werf, Frans, Baran, Kenneth W., Hobbach, Hans-Peter, Greenberg, Sally, Miller, Joanne, Kitt, Michael M., Strony, John, McCabe, Carolyn H., Braunwald, Eugene
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 16.04.2003
• Subjects: cTFC; TNK; aPTT; INTEGRITI; TIMI; PCI; TMPG; STEMI; CABG; MI; ICH
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/S0735-1097(03)00123-2

The goal of this study was to evaluate combinations of eptifibatide with reduced-dose tenecteplase (TNK) in ST-elevation myocardial infarction (STEMI). Glycoprotein IIb/IIIa inhibitors enhance thrombolysis. The role of combination therapy in clinical practice remains to be established. Patients (n = 438) with STEMI <6 h were enrolled. In dose-finding, 189 patients were randomized to different combinations of double-bolus eptifibatide and reduced-dose TNK. In dose-confirmation, 249 patients were randomized 1:1 to eptifibatide 180 μg/kg bolus, 2 μg/kg/min infusion, and 180 μg/kg bolus 10 min later (180/2/180) plus half-dose TNK (0.27 mg/kg) or standard-dose (0.53 mg/kg) TNK monotherapy. All patients received aspirin and unfractionated heparin (60 U/kg bolus; infusion 7 U/kg/h [combination], 12 U/kg/h [monotherapy]). The primary end point was Thrombolysis In Myocardial Infarction (TIMI) grade 3 epicardial flow at 60 min. In dose-finding, TIMI grade 3 flow rates were similar across groups (64% to 68%). Arterial patency was highest for eptifibatide 180/2/180 plus half-dose TNK (96%, p = 0.02 vs. eptifibatide 180/2/90 plus half-dose TNK). In dose-confirmation, this combination, compared with TNK monotherapy, tended to achieve more TIMI 3 flow (59% vs. 49%, p = 0.15), arterial patency (85% vs. 77%, p = 0.17), and ST-segment resolution (median 71% vs. 61%, p = 0.08) but was associated with more major hemorrhage (7.6% vs. 2.5%, p = 0.14) and transfusions (13.4% vs. 4.2%, p = 0.02). Intracranial hemorrhage occurred in 1.0%, 0.6%, and 1.7% of patients treated with any combination, eptifibatide 180/2/180 and half-dose TNK, and TNK monotherapy, respectively. Double-bolus eptifibatide (180/2/180) plus half-dose TNK tended to improve angiographic flow and ST-segment resolution compared with TNK monotherapy but was associated with more transfusions and non-cerebral bleeding. Further study is needed before this combination can be recommended for general use.