Drug-eluting stents and glycoprotein IIbIIIa inhibitors in the pharmacoinvasive management of ST elevation MI

Evaluation of: Sanchez, P, Gimeno F, Ancillo P et al.: Role of the paclitaxel-eluting stent and tirofiban in patients with ST elevation myocardial infarction undergoing postfibrinolysis angioplasty (GRACIA 3 Trial). Circ. Cardiovasc. Interv. 3, 297–307 (2010). In ST elevation myocardial infarction patients presenting to nonpercutaneous coronary intervention (PCI)-capable hospitals, a pharmacoinvasive strategy utilizing fibrinolysis with early but not immediate angiography is a reasonable reperfusion strategy. The optimal antiplatelet regimen and stent type has not been defined in this clinical setting. The article by Sanchez et al. reported a 2 × 2 factorial design trial of 436 ST segment elevation myocardial infarction patients treated with full-dose tenecteplase and adjunctive PCI, comparing outcomes in patients randomized to the glycoprotein IIbIIIa inhibitor tirofiban versus placebo 2 h after fibrinolysis and the paclitaxel drug-eluting stent versus the bare-metal stent. The median time between fibrinolysis and PCI was 5.16 h. Tirofiban did not improve measures of epicardial or myocardial perfusion and resulted in a significant increase in bleeding that negatively impacted on 1-year mortality. In the stent stratum, the paclitaxel drug-eluting stent resulted in less neointimal hyperplasia but this did not translate into lower rates of restenosis. Until further studies are completed, patients treated with fibrinolysis should receive antiplatelet therapy with aspirin and clopidogrel, without routine use of glycoprotein IIbIIIa inhibitors, and drug-eluting stents should be used at the discretion of the interventional cardiologist.