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New Drug Revolutionizes PTCA Results
by Gilbert Sita , M.D.

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The most common, immediate and feared complication of percutaneous transluminal coronary angioplasty (PTCA) is acute thrombosis in the treated artery. The most common disappointment of PTCA is the high (six month) recurrence rate after an initially successful vessel opening.

For M.C., who was experiencing his first heart attack at age 39, the prospect of recurring problems and multiple future procedures was discouraging. (See Case Study) In the emergency room, he was given ASA, nitrogylcerin and heparin, and his chest pain disappeared. An urgently-performed angiogram, however, showed a 90 percent narrowing of the proximal left anterior descending (LAD) artery and a thrombus at the site of the stenosis.

Because he was pain-free, intervention was temporarily postponed, an intra-aortic balloon pump was inserted to improve coronary blood flow, and he was maintained on ASA, heparin and ticlopidine.

The next day, M.C. underwent PTCA with stent insertion at the site of the LAD stenosis. Because of the thrombus seen on angiography, a new drug, ReoPro™, was administered. ReoPro™ is revolutionizing interventional cardiology by greatly reducing the threat of post-PTCA thrombosis.

ReoPro™ (abciximab) is a monoclonal-antibody Fab fragment which attaches itself to the IIb/IIIa glycoprotein receptor found on the surface of all platelets. By filling these binding sites, platelets cannot aggregate and thrombosis at the site of coronary intervention does not develop. (See Figure 1.)

Figure 1:
ReoPro™ attaches to IIb/IIIa receptors preventing fibrinogen and V.W. factor from initiating platelet aggregation.

Two large multi-center studies (EPIC¹ and EPILOG²) have conclusively shown that rates for death, MI or repeat revasculari-zation post-elective PTCA are dramatically lessened (30-50 percent) with the use of ReoPro™. In patients undergoing PTCA for AMI, the rates for these same complications were reduced by 83 percent at 30 days, and recurrent ischemia at six months was reduced by 43 percent.³

Some adjustments in other aspects of treatment are necessary when using ReoPro™. For example, a modified, lower-dose heparin regimen post-PTCA has reduced the initial high rates of hemorrhage seen when standard heparin dosing was concomitantly used. For those patients who require emergency bypass surgery due to a complication of angioplasty, and who received ReoPro™ during the PTCA, multiple platelet transfusions are necessary intra- and post-operatively to restore clotting parameters.

While the initial cost of ReoPro™ is high (approximately $1400 per patient), and while its use is not separately reimbursed by Medicare or managed care contracts, the savings accrued in reduced complications and recurrence more than covers this expense.⁴

In this case, M.C. recovered from the PTCA and stent insertion well, without any clotting problems, and was discharged home just 48 hours after arriving in the emergency room. A month later, stress echocardiography showed normal anterior wall motion and he remains symptom-free.

Thanks to ReoPro™, the inherent risk of thrombosis from PTCA and other interventional techniques is tremendously reduced, and patients are recovering from these procedures more quickly and with fewer complications. This helps make patients with heart disease far easier to manage in the primary care physician’s office.

¹New England Journal of Medicine, 1994; 330:956-61.
²New England Journal of Medicine, 1997; 336(24):1748-9.
³American Journal of Cardiology, May 15, 1996; 77(12):1045-51.
⁴Circulation, Aug. 15, 1996; 94(4):629-35.

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