ESC Congress News - Immediate emergency angioplasty can save the lives of those experiencing MI (CARESS)

ESC Daily Congress News

Immediate emergency angioplasty can save the lives of those experiencing MI

Authors:
Professor Carlo Di MarioUnited KingdomTel: +44 207 351 8616Fax+44 207 351 8629E-mail: c.dimario@rbht.nhs.uk

Hot Line II, CARESS in AMI Combined Abciximab RE-teplase Stent Study in Acute Myocardial Infarction, 707005

Vienna, Austria, 3 September 2007: We have demonstrated that patients who have an acute myocardial infarction and are admitted to a hospital which has no possibility to perform direct angioplasty, benefit from being transferred immediately after having received thrombolytics to a hospital where angioplasty (percutaneous coronary intervention, PCI, often including stent implantation) can be immediately performed.

Patients who are transferred and receive angioplasty immediately after thrombolytics are much more likely (4.1% vs. 11.1% at 30 days, p<0.001)> This advantage was present despite the fact that all the patients (36% of the entire conservative group) randomized to the group of more conservative treatment (no immediate transfer) were also promptly referred during the first hours post treatment if there was no evidence in their ECG/clinical status that the lytic drugs had open the occluded artery.

Clinical implications: When a patient cannot receive direct angioplasty, which unfortunately still includes the majority of the patients with acute myocardial infarction in most European countries, the current practice in most hospitals in Europe is to administer lytics and to wait, watching the effect of the drug on ECG and patient’s symptoms. It appears that this practice is wrong and all patients should be transferred immediately for angioplasty after thrombolysis is started. The reason why this does not happen, despite the fact that an ESC Guideline advises the practice, is because there was evidence from recent trials, namely ASSENT-4, reported in Lancet 2006; 367:569-68, that lytics immediately before PCI can be deleterious and increase the risk of adverse events, especially bleedings but also death and need for new emergency angioplasty.

We had an opposite result and we believe the reason is the type of lytic treatment used -- not just a thrombolytic drug, but a cocktail of a powerful intravenous anti-platelet agent called abciximab, and a reduced dose of a fibrin specific lytic drug called reteplase. This combination is very powerful and rapid in its action, with a synergistic effect demonstrated in previous trials and in in-vitro models, and achieved restoration of flow in the occluded artery in 85% of cases by the time patients reached the hospital where angioplasty was performed. Its main advantage is, however, the ability to inactivate platelets during the subsequent angioplasty, the opposite of the result observed when only lytics are given which tend to activate platelets instead.

IMPORTANT NOTE: This study will be presented immediately after a larger trial of almost 2,000 patients called FINESSE, with a PI from the Cleveland Clinic, Dr Stephen Ellis. The results of this second trial in AMI will be complementary to the CARESS results because FINESSE compares direct (primary) angioplasty with facilitated angioplasty using only abciximab or using the same combination of drugs we used in this trial. I expect the combined presentation of these 2 trials, with ours clearly positive and reaching unquestionable statistical significance with a favourable effects on all the endpoints (death, re-AMI and refractory ischaemia) will represent one of the highlights of this year’s ESC congress.