Coronary artery stenting for suboptimal PTCA results in acute myocardial infarction in patients treated with Abciximab: early and six-month outcome

Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial medical treatment of non-ST segment elevation acute coronary syndromes

BACKGROUND

During percutaneous coronary intervention (PCI), and in non-ST segment elevation acute coronary syndromes (NSTEACS), the risk of acute vessel occlusion by thrombosis is high. Glycoprotein IIb/IIIa blockers strongly inhibit platelet aggregation and may prevent mortality and myocardial infarction. This is an update of a Cochrane review first published in 2001, and previously updated in 2007 and 2010.

OBJECTIVES

To assess the efficacy and safety effects of glycoprotein IIb/IIIa blockers when administered during PCI, and as initial medical treatment in patients with NSTEACS.

SEARCH METHODS

We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 12, 2012), MEDLINE (OVID, 1946 to January Week 1 2013) and EMBASE (OVID, 1947 to Week 1 2013) on 11 January 2013.

SELECTION CRITERIA

Randomised controlled trials comparing intravenous IIb/IIIa blockers with placebo or usual care.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, assessed trial quality and extracted data. We collected major bleeding as adverse effect information from the trials. We used odds ratios (OR) and 95% confidence intervals (CI) for effect measures.

MAIN RESULTS

Sixty trials involving 66,689 patients were included. During PCI (48 trials with 33,513 participants) glycoprotein IIb/IIIa blockers decreased all-cause mortality at 30 days (OR 0.79, 95% CI 0.64 to 0.97) but not at six months (OR 0.90, 95% CI 0.77 to 1.05). All-cause death or myocardial infarction was decreased both at 30 days (OR 0.66, 95% CI 0.60 to 0.72) and at six months (OR 0.75, 95% CI 0.64 to 0.86), although severe bleeding was increased (OR 1.39, 95% CI 1.21 to 1.61; absolute risk increase (ARI) 8.0 per 1000). The efficacy results were homogeneous for every endpoint according to the clinical condition of the patients, but were less marked for patients pre-treated with clopidogrel, especially in patients without acute coronary syndromes.As initial medical treatment of NSTEACS (12 trials with 33,176 participants), IIb/IIIa blockers did not decrease mortality at 30 days (OR 0.90, 95% CI 0.79 to 1.02) or at six months (OR 1.00, 95% CI 0.87 to 1.15), but slightly decreased death or myocardial infarction at 30 days (OR 0.91, 95% CI 0.85 to 0.98) and at six months (OR 0.88, 95% CI 0.81 to 0.96), although severe bleeding was increased (OR 1.29, 95% CI 1.14 to 1.45; ARI 1.4 per 1000).

AUTHORS' CONCLUSIONS

When administered during PCI, intravenous glycoprotein IIb/IIIa blockers reduce the risk of all-cause death at 30 days but not at six months, and reduce the risk of death or myocardial infarction at 30 days and at six months, at a price of an increase in the risk of severe bleeding. The efficacy effects are homogeneous but are less marked in patients pre-treated with clopidogrel where they seem to be effective only in patients with acute coronary syndromes. When administered as initial medical treatment in patients with NSTEACS, these agents do not reduce mortality although they slightly reduce the risk of death or myocardial infarction.

Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial medical treatment of non-ST segment elevation acute coronary syndromes

BACKGROUND

During percutaneous coronary intervention (PCI), and in non-ST segment elevation acute coronary syndromes (NSTEACS), the risk of acute vessel occlusion by thrombosis is high. Glycoprotein IIb/IIIa blockers strongly inhibit platelet aggregation and may prevent mortality and myocardial infarction. This is an update of a Cochrane review first published in 2001, and previously updated in 2007 and 2010.

OBJECTIVES

To assess the efficacy and safety effects of glycoprotein IIb/IIIa blockers when administered during PCI, and as initial medical treatment in patients with NSTEACS.

SEARCH METHODS

We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 12, 2012), MEDLINE (OVID, 1946 to January Week 1 2013) and EMBASE (OVID, 1947 to Week 1 2013) on 11 January 2013.

SELECTION CRITERIA

Randomised controlled trials comparing intravenous IIb/IIIa blockers with placebo or usual care.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, assessed trial quality and extracted data. We collected major bleeding as adverse effect information from the trials. We used odds ratios (OR) and 95% confidence intervals (CI) for effect measures.

MAIN RESULTS

Sixty trials involving 66,689 patients were included. During PCI (48 trials with 33,513 participants) glycoprotein IIb/IIIa blockers decreased all-cause mortality at 30 days (OR 0.79, 95% CI 0.64 to 0.97) but not at six months (OR 0.90, 95% CI 0.77 to 1.05). All-cause death or myocardial infarction was decreased both at 30 days (OR 0.66, 95% CI 0.60 to 0.72) and at six months (OR 0.75, 95% CI 0.64 to 0.86), although severe bleeding was increased (OR 1.39, 95% CI 1.21 to 1.61; absolute risk increase (ARI) 8.0 per 1000). The efficacy results were homogeneous for every endpoint according to the clinical condition of the patients, but were less marked for patients pre-treated with clopidogrel, especially in patients without acute coronary syndromes.As initial medical treatment of NSTEACS (12 trials with 33,176 participants), IIb/IIIa blockers did not decrease mortality at 30 days (OR 0.90, 95% CI 0.79 to 1.02) or at six months (OR 1.00, 95% CI 0.87 to 1.15), but slightly decreased death or myocardial infarction at 30 days (OR 0.91, 95% CI 0.85 to 0.98) and at six months (OR 0.88, 95% CI 0.81 to 0.96), although severe bleeding was increased (OR 1.29, 95% CI 1.14 to 1.45; ARI 1.4 per 1000).

AUTHORS' CONCLUSIONS

When administered during PCI, intravenous glycoprotein IIb/IIIa blockers reduce the risk of all-cause death at 30 days but not at six months, and reduce the risk of death or myocardial infarction at 30 days and at six months, at a price of an increase in the risk of severe bleeding. The efficacy effects are homogeneous but are less marked in patients pre-treated with clopidogrel where they seem to be effective only in patients with acute coronary syndromes. When administered as initial medical treatment in patients with NSTEACS, these agents do not reduce mortality although they slightly reduce the risk of death or myocardial infarction.

Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial medical treatment of non-ST segment elevation acute coronary syndromes

BACKGROUND

During percutaneous coronary intervention (PCI), and in non-ST segment elevation acute coronary syndromes (NSTEACS), the risk of acute vessel occlusion by thrombosis is high. IIb/IIIa blockers strongly inhibit platelet aggregation and may prevent mortality and myocardial infarction (MI). This is an update of a Cochrane review first published in 2001, and previously updated in 2007.

OBJECTIVES

To assess the effects and safety of IIb/IIIa blockers when administered during PCI, and as initial medical treatment in patients with NSTEACS.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 3, 2009), MEDLINE (1966 to October 2009), and EMBASE (1980 to October 2009).

SELECTION CRITERIA

Randomised controlled trials comparing intravenous IIb/IIIa blockers with placebo or usual care.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, assessed trial quality and extracted data. We collected major bleeding as adverse effect information from the trials. Odds ratios (OR) and 95% confidence intervals (CI) were used for effect measures.

MAIN RESULTS

Forty-eight trials involving 62,417 patients were included. During PCI, IIb/IIIa blockers decreased mortality at 30 days (OR 0.76, 95% CI 0.62 to 0.95) and at six months (OR 0.84, 95% CI 0.71 to 1.00). Death or MI was decreased both at 30 days (OR 0.65, 95% CI 0.60 to 0.72), and at 6 months (OR 0.70, 95% CI 0.61 to 0.81), although severe bleeding was increased (OR 1.38, 95% CI 1.20 to 1.59; absolute risk increase (ARI) 8.0 per 1000). The efficacy results were homogeneous for every endpoint according to the clinical condition of the patients, but were less marked for patients pre-treated with clopidogrel, especially in patients without ACS.As initial medical treatment of NSTEACS, IIb/IIIa blockers did not decrease mortality at 30 days (OR 0.91, 95% CI 0.80 to 1.03) or at six months (OR 1.00, 95% CI 0.87 to 1.15), but slightly decreased death or MI at 30 days (OR 0.92, 95% CI 0.86 to 0.99) and at six months (OR 0.88, 95% CI 0.81 to 0.96), although severe bleeding was increased (OR 1.27, 95% CI 1.12 to 1.43; ARI 1.4 per 1000).

AUTHORS' CONCLUSIONS

When administered during PCI, intravenous IIb/IIIa blockers reduce the risk of death and of death or MI at 30 days and at six months, at a price of an increase in the risk of severe bleeding. The efficacy effects are homogeneous but are less marked in patients pre-treated with clopidogrel where they seem to be effective only in patients with ACS. When administered as initial medical treatment in patients with NSTEACS, these agents do not reduce mortality although they slightly reduce the risk of death or MI.

Platelet glycoprotein IIb/IIIa blockers for percutaneous coronary revascularization, and unstable angina and non-ST-segment elevation myocardial infarction

BACKGROUND

During percutaneous coronary revascularisation (i.e. coronary angioplasty (PTCA) with or without stent implantation), and in unstable angina/non-ST-segment elevation myocardial infarction, the risk of acute vessel occlusion by thrombosis is high in spite of treatment with aspirin and heparin. GP IIb/IIIa antagonists inhibit platelet aggregation and may prevent mortality and myocardial infarction.

OBJECTIVES

To assess the efficacy and safety of GP IIb/IIIa blockers during percutaneous coronary revascularisation, and in patients with unstable angina/non-ST-segment elevation myocardial infarction.

SEARCH STRATEGY

We searched the Cochrane Library (issue 1, 2000), MEDLINE (1966 to June 2001), EMBASE (1980 to Nov 1999), reference list of articles, medical websites and handsearch among abstracts from cardiology congresses.

SELECTION CRITERIA

Randomized controlled trials comparing intravenous GP IIb/IIIa blockers with standard medical treatment during percutaneous coronary revascularisation, and in patients with unstable angina/non-ST-segment elevation myocardial infarction.

DATA COLLECTION AND ANALYSIS

A list of titles and abstracts was screened separately by two reviewers who assessed trial quality and extracted data.

MAIN RESULTS

Percutaneous coronary revascularisation: Fourteen trials involving 17,788 patients were included. GP IIb/IIIa blockers were associated with decreased mortality at 30 days (OR 0.71 (95% CI 0.52, 0.97)) but not at 6 months (OR 0.85 (0.66, 1.11)). Mortality or infarction was decreased both at 30 days (OR 0.62 (0.55, 0.70); ARR: 31 per 1,000), and at 6 months (OR 0.65 (0.58, 0.73); ARR: 38 per 1,000)), but severe bleeding was increased (10 per 1,000; OR 1.38 (1.04, 1.85)). Unstable angina/non-ST-segment elevation myocardial infarction: Eight trials involving 30,006 patients were included. GP IIb/IIIa blockers were not associated with decreased mortality at 30 days (OR 0.90 (0.80, 1.02)) or at 6 months (OR: 1.01 (0.88, 1.16)). Mortality or infarction was decreased at 30 days (OR 0.91 (0.85, 0.98); ARR: 13 per 1,000)) and at 6 months (OR 0,88 (0.81, 0.95); ARR: 13 per 1,000)), although severe bleeding was increased (1 per 1,000; OR 1.27 (1.12, 1.44)).

REVIEWER'S CONCLUSIONS

Intravenous GP IIb/IIIa blockers reduce the risk of death at 30 days and markedly that of death or MI at 30 days and 6 months in patients submitted to percutaneous coronary revascularisation at a price of a moderate increased risk of severe bleeding. In contrast, in patients with unstable angina/non-ST-segment elevation myocardial infarction, these agents do not reduce mortality, only slightly reduce the risk of death or MI, and slightly increase the risk for severe bleeding.

Comparison of ReoPro((R)) (abciximab) versus intracoronary thrombolysis for early coronary stent thrombosis

AIMS: This study evaluated the treatment of early coronary stent thrombosis with intracoronary urokinase or the platelet glycoprotein IIb/IIIa receptor inhibitor ReoPro (abciximab). METHODS AND RESULTS: Seventy-four patients (126 stents) were treated immediately after identification of early (0-30 days) coronary stent thrombosis. Twenty-nine patients were treated with intracoronary urokinase (UK) (UK alone in 19; UK and additional balloon angioplasty in 10) and another 45 patients were given ReoPro((R)) (abciximab) (0.25 mg/kg as a bolus alone in 26, abciximab with additional balloon angioplasty in 19) within 30 days of stent implantation. TIMI grade 3 flow was obtained in 23 patients (79%) in the UK group and in 38 (84%) in the abciximab group (nonsignificant). Three patients (10%) in the UK group and one (2%) in the abciximab group underwent repeat percutaneous transluminal coronary angioplasty (PTCA) (nonsignificant). Five patients (17%) in the UK group and three (7%) in the abciximab group were referred for urgent coronary artery bypass graft surgery (CABG) because of residual thrombus and refractory ischemia (nonsignificant). Repeat revascularization was necessary in eight patients (28%) in the UK group versus four (9%) in the abciximab group (p < 0.05). Five patients (17%) in the UK group and eight (18%) in the abciximab group developed myocardial infarction (nonsignificant). Five patients (17%) in the UK group (cardiogenic shock (three), cerebral hemorrhage (one) and pneumonia (one)) and three (6.6%) in the abciximab group (cardiogenic shock (two), heart failure (one)) died within 30 days (nonsignificant). Overall, noncardiac complications (bleeding including surgical repair of groin) were observed in 11 patients (38%) in the UK group and three (7%) in the abciximab group (p < 0.001). CONCLUSION: Compared to urokinase, abciximab reduced the need for repeat revascularization procedures and the risk of noncardiac events, including bleeding complications in patients with early coronary stent thrombosis.

Hospital outcome after bailout coronary stenting in patients with acute myocardial infarction

We evaluated the outcome of bailout coronary stenting in acute myocardial infarction. Fifty patients (35 men, mean age 60 plusmn; 12) with acute myocardial infarction consecutively underwent bailout stenting after primary and rescue coronary angioplasty (n=41 and 9, respectively). Cardiogenic shock was present in six patients, and 17 others had contraindications to thrombolysis. Stent implantation was successful in 49/50 patients. The antithrombotic regimen combined heparin, aspirin, and ticlopidine. One patient had symptomatic stent closure. Predischarge angiography in 41/44 survivors showed widely patent stents in 40/41 patients. Six patients (4 of whom had been admitted with cardiogenic shock) died in the hospital. During acute myocardial infarction, bailout stenting can achieve high TIMI grade 3 coronary patency (here, 92%), and low acute stent closure rates (here, 2%). However, in-hospital mortality remained high, at nearly 10%, mainly due to the severe risk profile in this patient subset.