Meeting highlights: 46th Annual Scientific Sessions of the American College of Cardiology.

Acute Coronary Syndromes TIMI 14 (Final Results) Presenter: Elliott Antman, MD, Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass. The study: A prospective, multicenter, randomized, controlled trial of combined therapy with thrombolytic agents and the platelet glycoprotein IIb/IIIa antagonist abciximab in patients with AMI. A total of 681 patients were randomized to standard front-loaded tPA (100 mg), streptokinase (500 000, 750 000, 1 250 000, or 1 500 000 U) plus abciximab, low-dose tPA (20, 35, 50, or 65 mg) plus abciximab, or abciximab alone. In the streptokinase groups, lytic therapy was administered as a 30to 50-minute infusion. In the tPA groups, lytic therapy was administered as either a bolus, a bolus plus a 30-minute infusion, or a bolus plus a 60-minute infusion. The primary end point of the study was the incidence of TIMI grade 3 flow at 90-minute angiography. The results: The incidence of TIMI 3 flow at 90 minutes was 58% in the tPA-alone arm (n5146), 32% in the abciximab-alone arm (n531), and 42% (n536), 39% (n549), 47% (n547), and 80% (n55; discontinued because of excessive bleeding and excess mortality) in the respective streptokinase-plus-abciximab groups. In the tPA-plus-abciximab groups, the incidence of TIMI 3 flow at 90 minutes was 53% (20-mg bolus; n536), 38% (35-mg bolus; n540), 62% (15-mg bolus, 20-mg infusion over 30 minutes; n550), 54% (50-mg bolus; n528), 61% (15-mg bolus, 35-mg infusion over 30 minutes; n546), 79% (15-mg bolus, 35-mg infusion over 60 minutes; n534), and 71% (15-mg bolus, 50-mg infusion over 60 minutes; n531). A group that combined tPA (15-mg bolus, 35-mg infusion over 60 minutes) with higherdose abciximab (and reduced heparin) had a 90-minute TIMI 3 flow rate of 69% (n536). The incidence of major bleeding was 6% with tPA alone; 6% with abciximab alone; 5%, 8%, 14%, and 67% (discontinued arm) in the respective streptokinase groups; and 5%, 4%, 0%, 8%, 8%, 5%, and 0% in the respective tPA groups. The higher-dose abciximab group had a 15% incidence of major bleeding. Summary: Abciximab alone achieves TIMI 3 flow rates comparable to streptokinase alone (in prior studies). The combination of reduced-dose thrombolytic therapy and abciximab augments the rate and extent of thrombolysis. With streptokinase plus abciximab, there appears to be a doserelated increased risk of major bleeding, and unacceptably high rates of bleeding and mortality occur with full-dose streptokinase plus abciximab. The combination of reduceddose tPA (bolus plus infusion) with abciximab is a promising alternative to full-dose accelerated tPA.