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CLINICAL STUDIES

Reduction in complications of angioplasty with abciximab occurs largely independently of baseline lesion morphology

Stephen G. Ellis, MD^*, A. Michael Lincoff, MD^*, Dave Miller, MS, James E. Tcheng, MD, Neal S. Kleiman, MD, Dean Kereiakes, MD^||, Robert Califf, MD, Eric J. Topol, MD^* for the EPIC and EPILOG Investigators

^* Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Department of Biostatistics, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Department of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
University of Texas, Houston, Texas, USA
^|| The Christ Hospital, Cincinnati, Ohio, USA

Manuscript received March 17, 1998; revised manuscript received July 7, 1998, accepted July 24, 1998.

Address for correspondence: Dr. Stephen G. Ellis, The Cleveland Clinic Foundation, 9500 Euclid Avenue, F-25, Cleveland, Ohio 44195
elliss{at}cesmtp.ccf.org

	Abstract

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Objectives. We investigated the hypothesis that abciximab might lead to a differential effect among patients with different lesion morphologies; hence, its cost/benefit ratio would be optimized if it were used selectively on the basis of baseline angiographic findings.

Background. Major complications of coronary angioplasty occur in 4% to 9% of patients. In the Evaluation of 7E3 for the Prevention of Ischemic Complications (EPIC) and Evaluation of PTCA To Improve Long-term Outcome with abciximab GPIIb/IIIa Receptor Blockade (EPILOG) trials, abciximab decreased the ischemic complications after intervention by 35% to 56%. However, the cost of this agent is appreciable, and there remain concerns about the safety of its readministration.

Methods. There were 1,362 patients in EPIC and 2,792 patients in EPILOG randomized to either bolus plus an infusion of abciximab or placebo, administered with aspirin and heparin at the time of the coronary intervention. Data from these studies were combined, and a differential effect of abciximab in relation to baseline lesion morphology on 30-day risk of death, myocardial infarction or urgent intervention was investigated using the Breslow Day test for statistical interaction.

Results. Abciximab consistently reduced the relative risk of complications across all lesion morphologies studied, with the possible exception of patients treated with degenerated saphenous vein grafts (risk with placebo 16.3% vs. risk with abciximab 18.6%, Breslow Day test for interaction, p = 0.08). However, the absolute reduction of risk was somewhat greater in patients with more complex B2 or C lesions (7.6% and 5.8%, respectively) than in patients with morphologically simpler A or B1 lesions (3.7% and 3.2%, respectively).

Conclusions. The reduction of early adverse ischemic events associated with angioplasty by abciximab occurs largely independent of pretreatment morphology.

Abbreviations and Acronyms   ACC/AHA = American College of Cardiology/American Heart Association   ACT = activated clotting time   EPIC = Evaluation of 7E3 for the Prevention of Ischemic Complications (trial)   EPILOG = Evaluation of PTCA To Improve Long-term Outcome by c7E3 GPIIb/IIIa Receptor Blockade (trial)   GP = glycoprotein

This study was undertaken to ascertain whether treatment with abciximab, when used with balloon angioplasty or directional coronary atherectomy, might have had a differential effect on patients with different lesion morphologies—because if it did, this potent agent could be used to treat patients with the most to gain. We hypothesized that patients with lesions of complex or thrombus-associated morphologies might derive heightened benefit from platelet GPIIb/IIIa inhibition.

	Methods

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Study groups and treatment protocols.   The study protocols have been described in detail elsewhere (12,13). In brief, in the EPIC study, 2,099 patients at increased risk for ischemic complications of angioplasty or atherectomy by virtue of clinical presentation (unstable angina, postinfarct angina or acute myocardial infarction [MI]) or lesion morphology (9,10) gave written informed consent and were randomized to standard therapy (aspirin plus heparin), standard therapy plus intravenous bolus abciximab (0.25 mg/kg body weight) or standard therapy plus bolus (0.25 mg/kg) and infusion (10 µg/min for 12 h) abciximab administered in a double-blind fashion. In the EPILOG study, 2,792 patients eligible for angioplasty or atherectomy, and without unstable angina with associated electrocardiographic (ECG) changes or acute MI within the previous 24 h (the group shown to benefit most in the EPIC study) gave written informed consent and were randomized to bolus (0.25 mg/kg) and infusion (0.125 mg/kg per min [maximum 10 µg per min] for 12 h) of abciximab and one of two heparin regimens (target activated clotting time [ACT] 300 s or 200 s) or aspirin plus heparin (target ACT 300 s) therapy only. For the purposes of this analysis, because patients in the bolus-only arm in EPIC did not derive significant clinical benefit, the bolus plus infusion groups from both studies were combined, and the effect of therapy was assessed against that seen in the combined placebo groups from the two studies.

Study end points.   Data were collected by study coordinators on case report forms, and the veracity of source documentation was assured by study monitors before data entry. Both groups had no knowledge of the treatment received.

The primary end point of this study was identical to that in the EPILOG study and was a slight modification of the primary end point in EPIC—a composite of all-cause mortality, nonfatal MI and repeat revascularization for acute coronary ischemia occurring within the first 30 days after randomization. Events were classified by a consensus of at least two members of an independent end points committee that had no knowledge of the patients’ randomized treatment allocation.

Angiographic analysis.   Preintervention lesion characteristics and angiographic findings were reported by the investigators, using the following definitions: angulation (<45°, 45 to 60°, >60°), lesion calcification (none, mild, moderate, severe), lesion contour (smooth, irregular, ulcerated), lesion eccentricity, lesion length (<10 mm, 10 to 20 mm, >20 mm), modified American College of Cardiology/American Heart Association (ACC/AHA) lesion classification (10), ostial location, percent diameter stenosis (calipers), presence of a side branch (none, 1.0 to 1.9 mm, 2.0 to 2.4 mm, 2.5 mm), proximal tortuosity (none, two or more bends of 60° or one 90° bend, two or more 90° bends), Thrombolysis In Myocardial Infarction flow grade and thrombus (absent, possible, present). Definitions of the characteristics that are not explicitly defined have been previously published (9,10).

Statistical analysis.   Continuous data are presented as the mean value and interquartile range, and categoric variables are presented as percentages. For patients with more than one treated lesion (n = 702, 25.2%), a morphologic variable was considered to be present if it was apparent for any treated lesion in that patient. Separate and pooled univariate and multivariate analyses from the EPIC and EPILOG trials for each candidate morphologic variable were performed. Odds ratios and p values for the benefit of abciximab for each lesion morphology were calculated based on the Cochran–Mantel–Haenzel statistic. Breslow Day tests were performed to test for the possibility of an interaction between treatment and lesion morphology and to ascertain if there was a differential treatment effect in the EPIC and EPILOG trials. Using this test, p < 0.05 suggests a nonuniformity of benefit between morphologies or clinical trials, whichever is being tested. For all statistical tests, p < 0.05 was considered significant, although an assessment of the number of patients studied, as well as the relative and absolute risk reductions, was also considered. However, p values 0.10 are provided to assist in interpretation of the results.

	Results

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Patient characteristics and outcome.   Baseline clinical and end point data for the patients studied are presented in Table 1. The majority of patients were middle aged and male. By virtue of the inclusion criteria in the EPIC trial, refractory acute ischemic syndromes were less common in that study than in EPILOG. In the EPIC trial, balloon angioplasty was performed as sole treatment in 90% of the patients, whereas 4% had directional coronary atherectomy, 5% had both angioplasty and atherectomy and 0.9% had bailout stents. In the EPILOG study, those figures were 90%, 2% and 4%, respectively. In addition, elective stenting (for suboptimal results) was performed in 2.0%, rotational atherectomy in 0.5%, excimer laser in 0.3% and extraction atherectomy in 0.2% of patients as primary therapy. Bailout stenting was used as an adjunct procedure in 13% of patients in the EPILOG trial.

Effect of abciximab treatment on major ischemic complications.   The absolute risk of major ischemic complications and the odds ratios with Cochran–Mantel–Haenzel and Breslow Day statistics for the different lesion morphologies are presented in Figure 1 and Table 2. Importantly, the 95% confidence intervals for the odds ratios and the Cochran–Mantel–Haenzel determined p values are dependent on both the relative difference of the incidence of adverse events between the two treatment groups and on the number of patients studied. In general, the beneficial effect of abciximab extended across all lesion morphologies examined (with the possible exception of degenerated vein grafts, which appeared to possibly be resistant, Breslow Day test, p = 0.083), with the relative reduction in adverse events ranging from 73% (calcified lesions) to 27% (total occlusions). Expressed as an absolute reduction in adverse events, the beneficial abciximab effect was noted with all lesion morphologies, except for degenerated vein grafts, and had its most striking beneficial effect in angulated lesions (absolute reduction of 10.5%, p < 0.001), bifurcation lesions (absolute reduction of 11.0%, p = 0.047) and calcified lesions (absolute reduction 13.0%, p < 0.001). The absolute benefit of abciximab in preventing adverse effects at 30 days was somewhat more prominent for complex type B2 or C lesions (7.6% and 5.8%, respectively) than for simpler type A or B1 lesions (3.7% and 3.2%). Notably, the absolute reduction in adverse events noted with patients treated with thrombus-containing lesions was 6.3% (p < 0.001). Possible intertrial treatment differences, as assessed by Breslow Day testing, were noted for bifurcation lesions and possibly for tortuous and eccentric lesions also. Analyses limited to patients with a single treated site (n = 3,452) yielded essentially the same results with regard to the interaction between treatment and lesion morphology as the overall analysis.

View larger version (22K): [in this window] [in a new window]   Figure 1 Treatment effect of abciximab on 30-day adverse outcome for various lesion morphologies. LL = lesion length; Deg SVG = degenerated saphenous vein graft.

	Discussion

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Abciximab, by providing powerful blockade of the platelet GPIIb/IIIa receptor modulating platelet aggregation, was shown in both the EPIC and EPILOG trials to dramatically reduce ischemic complications of angioplasty and related interventions. Were it not for the cost of this agent and concerns about the risk of readministration (thrombocytopenia), one could cogently argue that all patients undergoing balloon angioplasty should have adjunctive abciximab therapy. Given these potential limitations, however, it would be advantageous to use this agent for patients most likely to benefit. The relative beneficial effect of abciximab on patients with varied lesion morphologies has not been studied, except in highly selected lesion types (17–19). However, one might postulate that lesions at greatest risk of thrombotic closure might benefit most. In contrast, the frequent association of deep dissection with thrombus might lead one to argue that all lesion types would benefit more or less equally.

Results.   In this evaluation involving 4,154 patients, we were unable to discern a strong differential effect of abciximab dependent on angiographically defined lesion type, with the possible exception of degenerated saphenous vein grafts, which tended to have less benefit. It should be noted, however, that this morphology was present in the least number of patients studied (n = 102), and therefore our study had the least power to detect a beneficial or detrimental effect in this group. The large benefit in dissection-prone lesions (angulated, bifurcation, calcified) is particularly noteworthy. One would infer that although the more complex lesion types (B2 and C) might more often yield dissection-mediated ischemia, thrombus plays a major role in most ischemic complications of balloon angioplasty in both simple and complex lesions.

Effect in degenerated saphenous vein grafts.   If there is indeed a lessened beneficial effect for patients with degenerated vein grafts, one might postulate 1) that the stimulus for thrombosis in this situation was more dependent on the coagulation cascade per se than on platelet activation; 2) that the stimulus for platelet activation was greater in such patients so as to overwhelm the partial blockade induced by abciximab; 3) or that the etiology of complications in these patients might be related more to embolization of the friable atheromatous plaque than to thrombosis per se. In this regard, it is notable that in an ex vivo system, Fernandez-Ortiz et al. (20) found that platelet deposition was four to five times greater when platelets were exposed to sections of human aorta with atheromatous core (soft core with abundant cholesterol crystals) as compared with collagen or foam cell rich material. Such atheroma are typically seen in degenerated vein grafts (21). The possible lesser beneficial effect for patients with total occlusions, although not approaching statistical significance, also merits comment. The older thrombi that typically complete a vessel’s occlusion, which likely were frequently present in this patient group (because acute occlusions were very uncommon in this patient group), may be somewhat more resistant to the beneficial effects of abciximab on platelet deposition or even platelet disaggregation (22).

Study limitations.   It is important to understand several limitations of this study. First, although the number of lesions treated is large in comparison to many other studies, the power to detect treatment–lesion type interactions is modest. Second, it is recognized that the interobserver variability for categorizing a lesion’s characteristics is considerable, with kappa values often in the range of 0.30 to 0.70, and lesion characteristics were assessed at the clinical site rather than at a core angiographic laboratory (10,23). This may undermine our power to detect special benefit in patients with certain lesion types, but reflects the "real world" assessment of lesion morphology. Third, the influence of abciximab on outcome in patients receiving stents cannot be defined. Apparent benefit has been previously reported in the setting of bailout stenting (24). Our results, therefore, are germane for the 30% to 50% of patients not treated with stents. Fourth, there appear to be some potential differences in the relative treatment effect between patients from the EPIC and EPILOG trials. By virtue of the inclusion criteria of EPIC, patients more frequently had refractory unstable angina in EPILOG, potentially explaining the possible differential effect noted. It is unlikely that the minor differences in treatment regimen between the two studies had any effect on this finding. It is also possible that one or more of these findings relates to the numerous statistical tests performed in an attempt to determine interactions. Fifth, as alluded to, we recognize that multiple statistical tests were performed to analyze the possibility of treatment interactions with these 11 specific lesion morphologies. The likelihood of a spurious finding (statistical type I error) is thereby heightened, and we would urge caution in the interpretation of borderline interaction-related p values (0.01 to 0.05). Finally, we recognize that a long-term reduction in ischemic events with abciximab in nondiabetic patients has also been reported from these studies, and the data we have analyzed pertain only to short-term outcome.

Study implications.   It appears, therefore, with the acknowledgement of the limitations noted, that the use of abciximab in conjunction with angioplasty should not be strongly predicated on angiographic morphology of the lesion(s) to be treated. As unstable symptoms also do not predict benefit (25), other issues such as the likely consequences of vessel closure (26) and bleeding risk (19) should be considered carefully in the decision to use this agent. The possible diminished effect noted with treatment of degenerated saphenous vein grafts should be analyzed in other patient groups.

	Acknowledgments

 
The authors express their gratitude to Ms. Patti Durnwald for her expert secretarial assistance in the preparation of this report.

	Footnotes

 
This study was supported by a grant from Centocor, Inc., Malvern, Pennsylvania.

	References

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