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CLINICAL RESEARCH: TREATMENT OF ACUTE INFARCTION WITH PCI

Angiographic variables predict increased riskfor adverse ischemic events after coronarystenting with glycoprotein IIb/IIIa inhibition

Results from the TARGET trial

Mitchell J. Ross, MD^*, Howard C. Herrmann, MD, FACC^*,*, David J. Moliterno, MD, FACC, James C. Blankenship, MD, FACC, Laura Demopoulos, MD, Peter M. DiBattiste, MD, FACC, Stephen G. Ellis, MD, FACC, Ziyad Ghazzal, MD, FACC^||, Jack L. Martin, MD, FACC^¶, Jennifer White and Eric J. Topol, MD, FACC

^* Division of Cardiology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
Division of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Division of Cardiology, Geisinger Medical Center, Danville, Pennsylvania, USA
Merck & Co., Inc., West Point, Pennsylvania, USA
^|| Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
^¶ Division of Cardiology, Bryn Mawr Hospital, Bryn Mawr, Pennsylvania, USA

Manuscript received December 4, 2002; revised manuscript received March 11, 2003, accepted March 13, 2003.

^* Reprint requests and correspondence: Dr. Howard C. Herrmann, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104, USA.
howard.herrmann{at}uphs.upenn.edu

OBJECTIVES: We sought to assess whether pre-procedural angiographic characteristics are associated with adverse clinical outcomes after coronary stenting with glycoprotein IIb/IIIa inhibition.

BACKGROUND: Ischemic complications after balloon angioplasty are associated with pre- and post-procedural angiographic variables. However, in the current era of stenting with IIb/IIIa inhibition, it is unknown whether angiographic features assessed before intervention confer an increased risk of adverse procedural and subsequent clinical outcomes.

METHODS: In the Do Tirofiban and ReoPro Give Similar Efficacy Outcomes? Trial (TARGET), 4,809 patients undergoing planned stenting were randomized to tirofiban or abciximab. Baseline demographic, clinical, and angiographic variables were obtained. Clinical end points were recorded at 30 days and six months. The relationship between angiographic variables and adverse clinical outcomes was assessed.

RESULTS: Patients with the combination of thrombus, lesion eccentricity, and lesion length >20 mm had a 21.4% composite incidence of death, myocardial infarction, or urgent target vessel revascularization (TVR) at 30 days, compared with 4.2% in those patients without these high-risk features (hazard ratio [HR] 3.24, p < 0.001). After adjustment, the risk was independently associated with thrombus (HR 1.40, p = 0.034), eccentricity (HR 1.67, p < 0.001), and lesion length >20 mm (HR 1.89, p < 0.001). The risk of six-month TVR was independently associated with left anterior descending coronary artery lesions (HR 1.46, p < 0.001), restenotic lesions at baseline (HR 1.58, p = 0.006), and lesion length (HR 1.19, p = 0.03).

CONCLUSIONS: Patients with thrombus, eccentric lesions, or lesion length >20 mm are at high risk for ischemic outcomes after coronary stenting, despite IIb/IIIa inhibition. Further research into novel anti-thrombotic therapies or procedural strategies is necessary for these patients.

Abbreviations and Acronyms   ACS = acute coronary syndrome   CK = creatine kinase   HR = hazard ratio   LAD = left anterior descending coronary artery   MI = myocardial infarction   PCI = percutaneous coronary intervention   PTCA = percutaneous transluminal coronary angioplasty   TARGET = Do Tirofiban and ReoPro Give Similar Efficacy Outcomes? trial   TVR = target vessel revascularization

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