Higher efficacy of pre-hospital tirofiban with longer pre-treatment time to primary PCI: protection for the negative impact of time delay

• Published in: EuroIntervention Vol. 7; no. 4; pp. 442 - 448
• Main Authors: HEESTERMANS, Ton, DE BOER, Menko-Jan, TEN BERG, Jurriën M, VAN 'T HOF, Amoud W. J, VAN WERKUM, Jochem W, MOSTERD, Arend, MARCEL GOSSELINK, A. T, DAMBRINK, Jan-Henk E, HOUWELINGEN, Gert Van, KOOPMANS, Petra, HAMM, Christian, ZIJLSTRA, Felix
• Format: Journal Article
• Language: English
• Published: Toulouse Société Europa Edition 01.08.2011
• Subjects: Aged; Ambulances; Angioplasty, Balloon, Coronary - adverse effects; Angioplasty, Balloon, Coronary - mortality; Aspirin - administration & dosage; Biological and medical sciences; Cardiology. Vascular system; Chi-Square Distribution; Coronary Angiography; Coronary heart disease; Double-Blind Method; Drug Administration Schedule; Drug Therapy, Combination; Emergency Medical Services; Female; Fibrinolytic Agents - administration & dosage; Health Services Accessibility; Heart; Heparin - administration & dosage; Humans; Logistic Models; Male; Medical sciences; Middle Aged; Myocardial Infarction - diagnostic imaging; Myocardial Infarction - drug therapy; Myocardial Infarction - mortality; Myocardial Infarction - therapy; Myocarditis. Cardiomyopathies; Netherlands; Outcome and Process Assessment (Health Care); Platelet Aggregation Inhibitors - administration & dosage; Risk Assessment; Risk Factors; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Ticlopidine - administration & dosage; Ticlopidine - analogs & derivatives; Time Factors; Treatment Outcome; Tyrosine - administration & dosage; Tyrosine - analogs & derivatives; Myocardial infarction; Cardiovascular disease; Time; Myocardial disease; Delay; duration of pre-treatment; Tirofiban; Efficiency; Primary; Antithrombotic agent; Hospital; Protection; Platelet glycoprotein IIb/IIIa receptor antagonist; Biological receptor; Glycoprotein IIbIIIa; glycoprotein IIb/IIIa receptor inhibitors; ST interval; Duration; Glycoprotein IIIa; Coronary heart disease; Antiplatelet agent; ST-segment deviation; Treatment; Deviation; Fibrinolytic
• ISSN: 1774-024X; 1969-6213
• DOI: 10.4244/EIJV7I4A73

To evaluate the impact of longer duration of pre-hospital initiated antiplatelet and antithrombotic therapy on outcome in patients with ST-segment elevation myocardial infarction (STEMI). In this sub-analysis of the Ongoing Tirofiban in Myocardial Evaluation (On-TIME) 2 trial, we studied, in 1,370 patients, the effect of pre-treatment time (time from administering study medication to time of angiography) on complete ST-segment resolution (STR), initial patency and 30-day mortality. Study medication consisted of high dose tirofiban (HDT) or control (placebo or no HDT) on top of high dose clopidogrel, aspirin and unfractionated heparin. Median pre-treatment time was 55 min (44-70). Longer pre-treatment was associated with longer transportation times, longer in-hospital delay, longer total ischaemic time (all p<0.001) and higher 30-day mortality (3.6% vs. 1.8%, p=0.046). Longer HDT pre-treatment time was independently associated with increased complete STR both before (odds ratio [OR] 1.51, 95%; confidence interval [CI] 0.98-2.32; p=0.06) and after PCI (OR 1.43, 95%; CI 1.02-2.02; p=0.039) and with a significantly improved initial TIMI 2 or 3 flow (51.4% vs. 43.4%, p=0.042) and reduced 30-day mortality (2.1% vs. 5.0%, p=0.047) as compared to longer control pre-treatment. Longer time delay before primary PCI is associated with increased mortality. Pre-treatment with high dose tirofiban, however, may compensate for this negative effect by improving ST-segment resolution and initial patency and by reducing mortality. Further studies should be performed to confirm that this is an attractive therapy for patients with longer delays to reperfusion.