Cardiovascular Journal of Africa: Vol 30 No 5 (October 2019)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 5, September/October 2019 AFRICA 285
Clinical outcome of intracoronary versus intravenous
high-dose bolus administration of tirofiban in diabetic
patients undergoing primary percutaneous coronary
intervention
Ahmed A Ghonim, Abdalla Mostafa, Ahmed Emara, Alaa S Algazzar, Mohammed A Qutub
Abstract
Background: Previous trials remain inconsistent regarding the
advantages and hazards related to intracoronary (IC) compared
with intravenous (IV) administration of thrombolytics. We
aimed to evaluate the safety and effectiveness of IC versus IV
tirofiban administration in diabetic patients (DM) with acute
ST-segment elevation myocardial infarction (STEMI) during
primary percutaneous coronary intervention (PCI).
Methods: This trial included 95 patients who were randomised
to high-dose bolus plus a maintenance dose of tirofiban
administered either IV or IC. The groups were compared
for the incidence of composite major adverse cardiac events
(MACE) at 30 days. Levels of cardiac markers were recorded
pre- and post-intervention for myocardial perfusion.
Results: The MACE were not different between the groups,
but post-procedure myocardial blush grade (MBG) 3 and
thrombolysis in myocardial infarction (TIMI) 3 flow were
significant in the IC group (p = 0.45, 0.21, respectively),
favouring the IC strategy. Peak values of both creatine
kinase-muscle/brain (CK-MB) and high-sensitivity troponin
T (hs-TnT) were significantly lower in the IC group (155.68 ±
121, 4291 ± 334 ng/dl) versus the IV group (192.4 ± 86, 5342 ±
286 ng/dl) (p = 0.021, p = 0.035, respectively). The peak value
was significantly lower in the IC group than the IV group in
terms of ST-segment resolution and 30-day left ventricular
ejection fraction (LVEF) (p = 0.016 and 0.023, respectively).
Conclusion: Thirty days post PCI, IC tirofiban was more
efficient in ameliorating blood flow in the coronary arteries
and myocardial tissue perfusion in DM patients after STEMI
despite bleeding events, and MACE rates showed no signifi-
cant difference between the groups. The IC group showed
better improvement in LVEF.
Keywords: diabetes mellitus, STEMI, intracoronary tirofiban,
primary coronary intervention
Submitted 12/1/19, accepted 6/5/19
Published online 12/6/19
Cardiovasc J Afr 2019; 30: 285–289
DOI: 10.5830/CVJA-2019-027
Impaired glucose metabolism accelerates the risk of
arteriosclerosis and 80% of patients with diabetes mellitus
(DM) die from cardiovascular diseases.1 Previous trials have
demonstrated a positive correlation between hyperglycaemia
and the occurrence of heart failure, arrhythmia and other
complications. Moreover, hyperglycaemia significantly increased
the mortality rate of patients with diabetes complicated by
myocardial infarction (MI).2
Acute occlusion of the major epicardial coronary artery
usually leads to acute ST-segment elevation myocardial infarction
(STEMI). Successful recanalisation and patency of the occluded
vessels with percutaneous coronary intervention (PCI) or
fibrinolytics diminishes the infarction size, saves the function of
the ventricle and decreases morbidity and mortality rates.3,4
Several consequences, such as no reflow and slow flow,
associated with more major adverse cardiac events (MACE),
complications and high mortality rates have been observed
in patients with DM complicated by acute MI (AMI) and
undergoing primary PCI. 5,6 Platelet aggregation into the distal
microvasculature or thrombus embolisation immediately
after successful intervention impairs microvascular flow.
Administration of glycoprotein IIb/IIIa inhibitors (GPI) and
many catheter-based strategies have been attempted to overcome
this phenomenon.7,8
American guidelines recommend tirofiban during PCI in
patients with STEMI for high burden of thrombus or patients
who received inadequate loading of P2Y12 inhibitors, and
in patients with non-ST-elevation acute coronary syndrome
(NSTE-ACS) and high risk.9,10 European guidelines recommend
tirofiban use in PCI for bailout situations if there is angiographic
evidence of massive thrombus, slow or no reflow, or thrombotic
complications. 11,12
This trial attempted to assess whether intracoronary (IC)
administration of high-dose bolus plus a maintenance-dose
infusion of tirofiban would lead to better efficacy and safety and
enhance clinical outcomes better than the standard intravenous
(IV) bolus-plus-infusion regimen during PCI for diabetic patients
with acute STEMI.
Department of Cardiovascular Medicine, Naser Institute for
Research and Therapy, Cairo, Egypt
Ahmed A Ghonim, MD
Cardiology Department, Menofia University, Almenofia Egypt
Abdalla Mostafa, MD
Ahmed Emara, MD
Cardiology Department, Ahmed Maher Teaching Hospital,
Cairo, Egypt
Alaa S Algazzar,MB BCh, MSc, FEBC,
Division of Cardiology, Department of Medicine, King
Abdulaziz University Hospital, Jeddah Saudi Arabia
Mohammed A Qutub, MD, FRCPC, FACP