Randomized Comparison of Eptifibatide Versus Abciximab in Primary Percutaneous Coronary Intervention in Patients With Acute ST-Segment Elevation Myocardial Infarction

Impact of maintenance dose of eptifibatide in patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) is usually caused by a rupture in the atherosclerotic plaque, followed by platelet aggregation which ultimately leads to acute coronary artery occlusion. So far, few studies have investigated the effect of maintenance dose of Eptifibatide (glycoprotein IIb/IIIa inhibitor) in STEMI patients who underwent primary percutaneous coronary intervention (PPCI). Therefore, in this study, we investigated the effect of maintenance dose of Eptifibatide in patients with STEMI who underwent PPCI. 264 patients who had acute chest pain suggestive of STEMI were entered in the study. All patients received the same dose of bolus dose of Eptifibatide in the cardiac catheterization laboratory. Then the patients were randomly divided into two groups, one group (n = 147) received a maintenance dose of intravenous Eptifibatide (infusion of 2 μg/kg/min) and the other group (n = 117) did not receive this treatment. Standard medical treatment of STEMI after PPCI was performed based on guidelines and the same in both groups. All patients were evaluated 1, 2, and 3 months after the start of treatment in terms of predicted outcomes.

RESULTS

The occurrence of 3-month major adverse cardiovascular events (MACE) between the case and control groups did not have a statistically significant difference (28.6% versus 35.0%; P value: 0.286). Also, investigations showed that the rate of re-infarction (P value: 0.024) and target lesion revascularization (P value: 0.003) was significantly lower in the group that received Eptifibatide infusion.

CONCLUSIONS

Eptifibatide maintenance dose infusion in patients who undergo PPCI in the context of STEMI, does not significantly reduce MACE, although it does significantly reduce re-infarction and target lesion revascularization. It also does not increase the risk of bleeding and cerebrovascular events.

The role of platelet glycoprotein IIb / IIIa inhibitors in current treatment of acute coronary syndrome

Current management of patients with acute coronary syndrome (ACS) includes a dual antiplatelet therapy with acetylsalicylic acid and a platelet P2Y12 receptor inhibitor. For patients without a high risk of bleeding, prasugrel and ticagrelor are preferred, since their effect is more pronounced, less dependent on metabolism of a specific patient, and occurs faster that the effect of clopidogrel. The prescription rate of platelet glycoprotein IIb/IIIa (GP IIb / IIIa) receptor inhibitors has considerably decreased. However, these drugs remain relevant in percutaneous coronary interventions in patients with a high risk of coronary thrombosis or a massive coronary thrombus, in thrombotic complications of the procedure, and in the "no-reflow" phenomenon. The intravenous route of GP IIb / IIIa inhibitor administration provides their effectiveness in patients with difficulties of drug intake or with impaired absorption of oral medications. This review presents clinical and pharmacological characteristics of various GP IIb / IIIa inhibitors and data of randomized clinical studies and registries of recent years that evaluated results of their use in patients with ACS.

Comparison of Routine Versus Selective Glycoprotein IIb/IIIa Inhibitors Usage in Primary Percutaneous Coronary Intervention (from the British Cardiovascular Interventional Society)

The role of glycoprotein IIb/IIIa inhibitors (GPI) in primary percutaneous coronary intervention (PPCI) remains uncertain. Previous analyses compare PPCI outcomes with clopidogrel plus GPI, versus without GPI. This does not reflect modern contemporary PPCI practice with ticagrelor or prasugrel. Nor does it answer the important question faced daily by PPCI operators: should GPI be used routinely or selectively? We aim to determine whether a strategy of routine use of GPI in contemporary PPCI practice is superior to selective GPI use. A total of 110,327 consecutive PPCIs performed in England were prospectively recorded in the British Cardiovascular Intervention Society Database (2009 to 2015). The cohort was divided into routine and selective GPI usage groups based on the PPCI operator's strategy, defined as GPI used in >75% and <25% PPCIs, respectively. Overall, GPI use declined from 73.1% to 43.3% of PPCIs. Routine compared with selective GPI usage was associated with lower all-cause 1-year mortality: 9.7% versus 11.0%, p < 0.001. There was a consistent survival benefit for routine GPI usage as compared with selective GPI usage: univariable analysis (hazard ratio = 0.88 [95% confidence interval 0.83 to 0.93], p < 0.001), multivariable analysis (hazard ratio = 0.82 [0.77 to 0.88], p < 0.001). For survival, there was no interaction between GPI usage and the type of P2Y12-inhibitor used. In conclusion, a strategy of routine GPI usage in patients who underwent PPCI was associated with lower all-cause mortality as compared with selective GPI usage. This benefit was maintained despite 44.3% of patients receiving prasugrel or ticagrelor.

Procedural and Clinical Outcomes in Management of Bifurcational Lesions in ST Elevation Myocardial Infarction

BACKGROUND

Bifurcation percutaneous coronary intervention (PCI) remains a challenging frontier in interventional cardiology, especially in the setting of ST-elevation myocardial infarction (STEMI). We examined the procedural and clinical outcomes of this patient subset.

METHODS

We conducted a retrospective case-control study. Between February 2006 and March 2011, 129 patients with STEMI underwent bifurcation PCI at our institution. One hundred and twenty-nine (129) control STEMI patients with non-bifurcation PCI were selected from the institutional database, matched for age, gender, culprit vessel, and lesion location. Patients with cardiac arrest, cardiogenic shock, or who required mechanical ventilation were excluded. Twelve (12)-month follow-up data were collected by telephone calls and examination of the medical records.

RESULTS

The average age of patients presenting with STEMI was 61.6 ± 13.1 in the bifurcation group and 61.5 + 31.1 in the non-bifurcation group. There was no difference in lesion type, use of thrombus aspiration catheters, or glycoprotein inhibitors (GPI) among them. Also, the use of drug eluting stent (DES), total cumulative length of stent used, and diameter of the post-dilation balloon were similar. Final kissing balloon post-dilation was performed in 40.3% of bifurcation PCI cases. The incidence of procedural failure (TIMI 0 flow) was 1.5% vs. 0%; p = 0.478. At 12-months follow-up, the bifurcation PCI group had higher incidence of target lesion revascularisation (TLR) (10.9% vs. 3.9%, p = 0.050), mortality (10.1% vs. 2.3%, p = 0.020), and stent thrombosis (9.3% vs. 1.6%; p = 0.013); comprising one acute, nine subacute, and two late vs. two subacute stent thromboses.

CONCLUSIONS

During acute STEMI, bifurcation PCI has excellent acute procedural outcomes, but significantly increased incidence of TLR, stent thrombosis and mortality at 12 months.

Comparison between Bolus Intracoronary versus Bolus Intravenous Injection Regimens of Eptifibatide during Primary Percutaneous Coronary Intervention in Patients with Anterior ST-Segment Elevation Myocardial Infarction

Background.Eptifibatide achieves high local concentration via direct intracoronary (I/V) injection as it promotes clot disaggregation, but it remains unclear if it is of superior benefit than the routine intravenous (I/V) administration. Aim. The current study aimed to examine the safety and efficacy of I/C vs I/V bolus regimen dose of eptifibatide during primary percutaneous coronary intervention (PPCI).

Material and methods. Prospective, controlled, randomized study enrolled 100 patients with acute anterior ST-segment elevation myocardial infarction (STEMI) eligible for PPCI equally divided into 2 groups (group A received bolus I/C eptifibatide and group B received it I/V) followed by 12-hour continuous I/V infusion. Features related to of myocardial salvage in the form of TIMI flow grade 3, myocardial blush grade 3, ST segment resolution and left ventricular systolic function were evaluated with short-term follow up for 1 month.

Results. Mean age of the study population was 50.95±8.45years, there was statistically insignificant difference between both groups regarding baseline characteristics in age (p=0.062), gender (p=0.488), coronary artery disease risk factors (p>0.05), time from onset of pain to admission (p=0.86) or door to balloon (p=0.12). Group A achieved statistically significant better myocardial blush grade 3 (42% vs 10%, p=0.005), ejection faction 30 days after PPCI (46.11±7.81% vs 40.88±6.26%, p=0.005) but statistically insignificant TIMI flow grade 3 (p=0.29) and ST resolution (p=0.34). Incidence of complications in the hospital and 30 days after discharge was statistically insignificant (p>0.05).

Conclusion. Both regimens were safe and effective in STEMI patients undergoing PPCI and regimen of I/C bolus eptifibatide achieved better myocardial blush grade and systolic function. 

German contribution to development and innovations in the management of acute myocardial infarction and cardiogenic shock

Treatment of acute coronary syndromes has evolved over time leading to a significantly reduced mortality. Multiple major trials have been performed in Germany leading to new treatment strategies in acute coronary syndromes including cardiogenic shock. This review article will summarize major trials and their impact on guideline recommendations in acute myocardial infarction highlighting reperfusion strategies, antiplatelet regimens, prognosis assessment and also mechanical circulatory support in stable infarction patients and in cardiogenic shock.

Cost assessment of treatment of acute myocardial infarction and angiographically visible coronary thrombus

AIM

Study was aimed to assess the real-world costs of manual thrombectomy (MT) in selected ST-segment elevation myocardial infarction patients with intracoronary thrombus (IT).

METHODS

Study group (IT+) comprised 51 patients with MT applied and control group (IT-) comprised 56 patients without IT who underwent angioplasty alone. Costs comprised hospital care and cost of disposable materials used during primary angioplasty.

RESULTS

Complex management of patients with IT is more expensive, though allows to achieve clinical outcomes comparable to low-risk ST-segment elevation myocardial infarction patients without IT.

CONCLUSION

A complex pharmaco-interventional strategy, with glycoprotein IIB/IIIA inhibitor and MT, though more expensive, may prove cost-effective.

Eptifibatide is associated with significant cost savings and similar clinical outcomes to abciximab when used during primary percutaneous coronary intervention for ST-elevation myocardial infarction: An observational cohort study of 3863 patients

INTRODUCTION

Glycoprotein IIb/IIIa inhibitors are recommended by guidelines in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. There are few studies directly comparing these agents. The aim of this study was to assess whether eptifibatide is a safe and cost-effective alternative to abciximab in the treatment of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction.

METHODS

This was an observational cohort study of 3863 patients who received a GPIIb/IIIa inhibitor whilst undergoing primary percutaneous coronary intervention from 2007 to 2014. Patients who did not receive a GPIIb/IIIa inhibitor were excluded. Time to first major adverse cardiac event defined as death, non-fatal myocardial infarction, stroke or target vessel revascularization, and total hospital costs were compared between the groups.

RESULTS

In all, 1741 patients received abciximab with 2122 receiving eptifibatide. Patients who received eptifibatide had higher rates of previous MI/percutaneous coronary intervention and were more likely to undergo a procedure from the radial route. Unadjusted Kaplan-Meier analysis revealed no significant difference in the 1-year event rates between patients given eptifibatide versus abciximab (p = 0.201). Age-adjusted Cox analysis demonstrated no difference in 1-year outcome between abciximab and eptifibatide (hazard ratio: 0.83; 95% confidence interval: 0.73-1.39), which persisted after multivariate adjustment (hazard ratio: 0.92; 95% confidence interval: 0.79-1.56) including the incorporation of a propensity score (hazard ratio: 0.88; 95% confidence interval: 0.71-1.44). Eptifbatide was associated with significant cost savings being 87% cheaper overall compared to abciximab (on average £650 cheaper per patient and saving approximately £950,000).

CONCLUSION

This observational data suggest that eptifibatide is associated with similar outcomes and significant cost savings compared to abciximab when used in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

The risk of bleeding with the use of antiplatelet agents for the treatment of cardiovascular disease

INTRODUCTION

In the presence of injured coronary vascular endothelium, platelets become activated to form hemostatic plugs. While this represents a normal healing response to disrupted vascular endothelium, occlusive cardiovascular disease, as a result of maladaptive thrombus formation, is a major cause of morbidity and mortality. Due to the platelet predominance of arterial thrombi, antiplatelet agents are the mainstay of therapy for arterial cardiovascular disease, though come with a significantly increased risk of bleeding. Areas covered: This review will provide a comprehensive overview of available antiplatelet agents used to treat coronary artery cardiovascular disease. The risks of bleeding with each agent will be considered. Expert opinion: Available antiplatelet therapies are effective in treating acute thrombotic events and preventing recurrent events, however, they also carry significant bleeding risks. The decision to use or continue antiplatelet agents remains challenging for physicians and necessitates a thorough understanding of the future risk of thrombotic risks of thrombotic or bleeding events in a patient. Clinical prediction rules and risk scores may be useful to support physician decision-making.

Comparison of heparin, bivalirudin, and different glycoprotein IIb/IIIa inhibitor regimens for anticoagulation during percutaneous coronary intervention: A network meta-analysis

BACKGROUND/PURPOSE

Numerous GPIs are available for PCI. Although they were tested in randomized controlled trials, a comparison between the different GPI strategies is lacking. Thus, we performed a Bayesian network meta-analysis to compare different glycoprotein IIb/IIIa inhibitor (GPI) strategies with heparin and bivalirudin for percutaneous coronary intervention (PCI).

METHODS

MEDLINE, Cochrane CENTRAL, and ClinicalTrials.gov were searched by two independent reviewers for randomized controlled trials comparing high-dose bolus tirofiban, abciximab, eptifibatide, heparin with provisional glycoprotein IIb/IIIa inhibitors, and bivalirudin with provisional GPI that reported clinical outcomes. Mixed treatment comparison model generation was performed to directly and indirectly compare between different anticoagulation strategies for all-cause mortality, myocardial infarction, major adverse cardiovascular events, major bleeding, minor bleeding, need for transfusion, and thrombocytopenia.

RESULTS

A total of 41 randomized controlled trials with 38,645 patients were included in the analysis, among which 2654 were randomized to high-dose bolus tirofiban, 6752 to abciximab, 1669 to eptifibatide, 16,500 to heparin, and 11,070 to bivalirudin. Mean age was 64±11years, 75% were male, 91% were treated with stenting, 71% with clopidogrel, and 74% for acute coronary syndrome. High-dose bolus tirofiban was associated with a significant reduction in all-cause mortality compared with heparin (OR 0.57 [credible intervals 0.37, 0.9]) and eptifibatide (OR 0.44 [credible intervals 0.19, 1.0]). GPI regimens had less myocardial infarction and major adverse cardiovascular events but greater bleeding compared with heparin and bivalirudin. There was no difference among the GPI therapies for other outcomes, including myocardial infarction, major adverse cardiovascular events, and major bleeding.

CONCLUSIONS

Our network meta-analysis of 38,645 patients demonstrated that GPI regimens were associated with a reduction in recurrent myocardial infarction or major adverse cardiovascular events for PCI, while bivalirudin was associated with the lowest risk of bleeding.

Patients with subarachnoid haemorrhage from vertebrobasilar dissection: treatment with stent-in-stent technique

INTRODUCTION

Vertebrobasilar dissection is an uncommon cause of subarachnoid haemorrhage (SAH) that carries a high risk for early repeat haemorrhage. The need for rapid treatment of this disease entity is without question; however, the best method for treatment is still undetermined. Here, we present our results using the stent-in-stent technique, without coiling, for these patients and propose that it is a viable treatment strategy.

METHODS

We identified in our local database for neurointerventional therapy, between 1st October 2000 and 1st January 2014, 93 patients with potential subarachnoid haemorrhage secondary to vertebrobasilar pathology. After review of the clinical notes and imaging, 15 were found to have presented with subarachnoid haemorrhage and treated with stents alone. All dissections were spontaneous with no history of preceding trauma. The ages ranged between 46 and 71 years (mean 61 years).

RESULTS

All patients presented with Fischer grade 4 SAH and had a visible pseudoaneurysm. The pre-operative GCS varied with two patients scoring 3, one patient scoring 6 and the remaining 12 patients scoring 8 or above. All cases were subjected to stent-in-stent treatment alone. We did not experience any intra-procedural complications. In our series, eight patients had full recovery with a Glasgow Outcome Scale (GOS) of 5, three had moderate disability (GOS 4), one had severe disability (GOS 3), and three patents died, one patient from stent thrombosis or re-bleeding and two from their initial SAH.

CONCLUSION

The stent-in-stent technique represents a viable reconstructive endovascular surgical technique with a low risk of intra-procedural complication and post-operative repeat haemorrhage.

Cardioprotective potential of annexin-A1 mimetics in myocardial infarction

Myocardial infarction (MI) and its resultant heart failure remains a major cause of death in the world. The current treatments for patients with MI are revascularization with thrombolytic agents or interventional procedures. These treatments have focused on restoring blood flow to the ischemic tissue to prevent tissue necrosis and preserve organ function. The restoration of blood flow after a period of ischemia, however, may elicit further myocardial damage, called reperfusion injury. Pharmacological interventions, such as antioxidant and Ca(2+) channel blockers, have shown premises in experimental settings; however, clinical studies have shown limited success. Thus, there is a need for the development of novel therapies to treat reperfusion injury. The therapeutic potential of glucocorticoid-regulated anti-inflammatory mediator annexin-A1 (ANX-A1) has recently been recognized in a range of systemic inflammatory disorders. ANX-A1 binds to and activates the family of formyl peptide receptors (G protein-coupled receptor family) to inhibit neutrophil activation, migration and infiltration. Until recently, studies on the cardioprotective actions of ANX-A1 and its peptide mimetics (Ac2-26, CGEN-855A) have largely focused on its anti-inflammatory effects as a mechanism of preserving myocardial viability following I-R injury. Our laboratory provided the first evidence of the direct protective action of ANX-A1 on myocardium, independent of inflammatory cells in vitro. We now review the potential for ANX-A1 based therapeutics to be seen as a "triple shield" therapy against myocardial I-R injury, limiting neutrophil infiltration and preserving both cardiomyocyte viability and contractile function. This novel therapy may thus represent a valuable clinical approach to improve outcome after MI.

Impact of Timing of Eptifibatide Administration on Preprocedural Infarct-Related Artery Patency in Acute STEMI Patients Undergoing Primary PCI

The appropriate timing of eptifibatide initiation for acute ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) remains unclear. This study aimed to analyze the impact of timing of eptifibatide administration on infarct-related artery (IRA) patency in STEMI patients undergoing primary PCI. Acute STEMI patients who underwent primary PCI (n = 324) were enrolled in this retrospective study; 164 patients received eptifibatide bolus ≤ 30 minutes after emergency department (ED) admission (group A) and 160 patients received eptifibatide bolus > 30 minutes after ED admission (group B). The primary endpoint was preprocedural IRA patency. Most patients in group A (90%) and group B (89%) were late presenters (> 2 hours after symptom onset). The two groups had similar preprocedural thrombolysis in myocardial infarction 2 or 3 flow of the IRA (26 vs. 24%, p = not significant [NS]), similar creatine kinase-MB (CK-MB) levels at 8 hours after admission (339 vs. 281 U/L, p = NS), similar left ventricular ejection fraction (LVEF) (52 vs. 50%, p = NS), and similar 30-day mortality (2 vs. 7%, p = NS). Compared with group B, patients in group A had shorter door-to-device time (p < 0.001) and shorter procedural time (p = 0.004), without increased bleeding risk (13 vs. 18%, p = NS). Earlier intravenous administration of eptifibatide before primary PCI did not improve preprocedural IRA patency, CK-MB level at 8 hours after admission, LVEF and 30-day mortality compared with patients who received intravenous eptifibatide that was administered later.

Clinical and economic studies of eptifibatide in coronary stenting

Platelet adhesion and aggregation at the site of coronary stenting can have catastrophic clinical and economic consequences. Therefore, effective platelet inhibition is vital during and after percutaneous coronary intervention. Eptifibatide is an intravenous antiplatelet agent that blocks the final common pathway of platelet aggregation and thrombus formation by binding to glycoprotein IIb/IIIa receptors on the surface of platelets. In clinical studies, eptifibatide was associated with a significant reduction of mortality, myocardial infarction, or target vessel revascularization in patients with acute coronary syndrome undergoing percutaneous coronary intervention. However, recent trials conducted in the era of dual antiplatelet therapy and newer anticoagulants failed to demonstrate similar results. The previously seen favorable benefit of eptifibatide was mainly offset by the increased risk of bleeding. Current American College of Cardiology/American Heart Association guidelines recommend its use as an adjunct in high-risk patients who are undergoing percutaneous coronary intervention with traditional anticoagulants (heparin or enoxaparin), who are not otherwise at high risk of bleeding. In patients receiving bivalirudin (a newer safer anticoagulant), routine use of eptifibatide is discouraged except in select situations (eg, angiographic complications). Although older pharmacoeconomic studies favor eptifibatide, in the current era of P2Y12 inhibitors and newer safer anticoagulants, the increased costs associated with bleeding make the routine use of eptifibatide an economically nonviable option. The cost-effectiveness of eptifibatide with the use of strategies that decrease the bleeding risk (eg, transradial access) is unknown. This review provides an overview of key clinical and economic studies of eptifibatide well into the current era of potent antiplatelet agents, novel safer anticoagulants, and contemporary percutaneous coronary intervention.

Rescue treatment of thromboembolic complications during endovascular treatment of cerebral aneurysms: a meta-analysis

BACKGROUND AND PURPOSE

Intraprocedural thrombus formation during endovascular treatment of intracranial aneurysms is often treated with glycoprotein IIb/IIIa inhibitors and, in some instances, fibrinolytic therapy. We performed a meta-analysis evaluating the safety and efficacy of GP IIb/IIIa inhibitors compared with fibrinolysis. We also evaluated the safety and efficacy of abciximab, an irreversible inhibitor, compared with tirofiban and eptifibatide, reversible inhibitors of platelet function.

MATERIALS AND METHODS

We performed a comprehensive literature search for studies on rescue therapy for intraprocedural thromboembolic complications with glycoprotein IIb/IIIa inhibitors or fibrinolysis during endovascular treatment of intracranial aneurysms. We studied rates of periprocedural stroke/hemorrhage, procedure-related morbidity and mortality, immediate arterial recanalization, and long-term good clinical outcome. Event rates were pooled across studies by using random-effects meta-analysis.

RESULTS

Twenty-three studies with 516 patients were included. Patients receiving GP IIb/IIIa inhibitors had significantly lower perioperative morbidity from stroke/hemorrhage compared with those treated with fibrinolytics (11.0%; 95% CI, 7.0%-16.0% versus 29.0%; 95% CI, 13.0%-55.0%; P = .04) and were significantly less likely to have long-term morbidity (16.0%; 95% CI, 11.0%-21.0% versus 35.0%; 95% CI, 17.0%-58.0%; P = .04). There was a trend toward higher recanalization rates among patients treated with glycoprotein IIb/IIIa inhibitors compared with those treated with fibrinolytics (72.0%; 95% CI, 64.0%-78.0% versus 50.0%; 95% CI, 28.0%-73.0%; P = .08). Patients receiving tirofiban or eptifibatide had significantly higher recanalization rates compared with those treated with abciximab (83.0%; 95% CI, 68.0%-91.0% versus 66.0%; 95% CI, 58.0%-74.0%; P = .05). No difference in recanalization was seen in patients receiving intra-arterial (77.0%; 95% CI, 66.0%-85.0%) or intravenous GP IIb/IIIa inhibitors (70.0%; 95% CI, 57.0%-80.0%, P = .36).

CONCLUSIONS

Rescue therapy with thrombolytic agents resulted in significantly more morbidity than rescue therapy with glycoprotein IIb/IIIa inhibitors. Tirofiban/eptifibatide resulted in significantly higher recanalization rates compared with abciximab.

Complications of intracoronary abciximab bolus-only versus standard protocol during percutaneous coronary intervention in acute coronary syndrome

BACKGROUND

Abciximab reduces major adverse cardiac events in patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention (pPCI). Standard protocol is intravenous abciximab bolus during PCI plus abciximab infusion for 12-18 h post pPCI. Intracoronary (IC) abciximab bolus administration results in high local drug concentrations and hence it should have higher antiplatelet effect. In this study, we assess the short-term efficacy and safety of IC compared to IV bolus of abciximab in ACS patients during pPCI.

METHODS

We compared the clinical outcomes between the IC (n = 56) and standard protocol (n = 170) group of patients. Primary endpoints included bleeding/vascular/ischemic complications and MACE.

RESULTS

The two groups were similar with respect to baseline characteristics. IC abciximab bolus only reduced bleeding complications, with no moderate bleed versus 7.2% in standard protocol group (p value 0.04). Ischemic/vascular complications had statistically insignificant difference between the two groups.

CONCLUSION

We found no significant difference between IC abciximab bolus only and standard abciximab therapy in terms of ischemic/vascular complications and MACE. But there was higher risk of moderate bleed in standard therapy group. The IC bolus route of abciximab may be superior to the intravenous route. Prospective randomized trials are warranted to validate these findings.

Beneficial effects of intracoronary nicorandil on microvascular dysfunction after primary percutaneous coronary intervention: demonstration of its superiority to nitroglycerin in a cross-over study

PURPOSE

In patients undergoing primary percutaneous coronary intervention (PCI) for the treatment of ST-segment elevation myocardial infarction (STEMI), coronary microvascular dysfunction is associated with poor prognosis. Coronary microvascular resistance is predominantly regulated by ATP-sensitive potassium (KATP) channels. The aim of this study was to clarify whether nicorandil, a hybrid KATP channel opener and nitric oxide donor, may be a good candidate for improving microvascular dysfunction even when administered after primary PCI.

METHODS

We compared the beneficial effects of nicorandil and nitroglycerin on microvascular function in 60 consecutive patients with STEMI. After primary PCI, all patients received single intracoronary administrations of nitroglycerin (250 μg) and nicorandil (2 mg) in a randomized order; 30 received nicorandil first, while the other 30 received nitroglycerin first. Microvascular dysfunction was evaluated with the index of microcirculatory resistance (IMR), defined as the distal coronary pressure multiplied by the hyperemic mean transit time.

RESULTS

As a first administration, nicorandil decreased IMR significantly more than did nitroglycerin (median [interquartile ranges]: 10.8[5.2-20.7] U vs. 2.1[1.0-6.0] U, p=0.0002).As a second administration, nicorandil further decreased IMR, while nitroglycerin did not (median [interquartile ranges]: 6.0[1.3-12.7] U vs. -1.4[-2.6 to 1.3] U, p<0.0001). The IMR after the second administration was significantly associated with myocardial blush grade, angiographic TIMI frame count after the procedure, and peak creatine kinase level.

CONCLUSION

Intracoronary nicorandil reduced microvascular dysfunction after primary PCI more effectively than did nitroglycerin in patients with STEMI, probably via its KATP channel-opening effect.

Clinical outcomes and cost implications of routine early PCI after fibrinolysis: one-year follow-up of the Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) study

BACKGROUND

In patients with ST-elevation myocardial infarction treated with fibrinolysis, routine early percutaneous coronary intervention (r-PCI) improves clinical outcomes at 30 days compared with a more standard approach of performing early PCI only for failed fibrinolysis (s-PCI).

METHODS

We report prespecified secondary clinical outcomes and cost implications of r-PCI compared with s-PCI from the Canadian TRANSFER-AMI trial. Average cost per patient in each arm was calculated based on a microcosting approach. Bootstrap method (5,000 samples) was used to calculate standard errors and 95% CI.

RESULTS

At 1 year, rates of death or reinfarction (10.3% vs 11.6%, P = .50), hospital readmission (15.4% vs 16.5%, P = .64) and subsequent revascularization after index hospitalization (6.9% vs 8.7%, P = .30) were similar between the r-PCI and s-PCI arms. The difference in cost per patient between r-PCI and s-PCI was CAD $1,003 (95% CI, -$247 to $2,211). Since a greater proportion of patients were transported by air (vs land) in the r-PCI arm (9.4% vs 3%), and the ratio of abciximab to eptifibatide use was higher in the r-PCI arm compared with s-PCI (2:1 vs 4:5), we undertook additional post hoc cost scenario analyses. In a scenario where patients are transported by land only and eptifibatide is used as the sole GPIIb/IIIa inhibitor, the difference in cost per patient between r-PCI and s-PCI was estimated to be CAD $108 (95% CI, -$1,114 to $1,344).

CONCLUSIONS

At 1 year, there is no difference in the clinical composite outcome of death or reinfarction between r-PCI and s-PCI strategies. Greater cost with r-PCI, although statistically insignificant, is economically important.

Pharmaco-mechanic antithrombotic strategies to reperfusion of the infarct-related artery in patients with ST-elevation acute myocardial infarctions

Primary percutaneous coronary intervention is the best treatment of patients with ST elevation myocardial infarction (STEMI). When managing a STEMI patient, our approach must be rapid and aggresive in order to interrupt the pathological process of thrombus formation and stabilization. The therapy must be initiated prior to angiography (pretreatment), continued during the procedure (periprocedural), recovery phase (in-hospital), and follow-up. The treatment strategies resulting in thrombus dissolution/extraction have focused on optimization of both pharmacological and interventional therapies. At present, there is no optimal evidence-based approach to all patients with STEMI, and the treatment of these patients needs to be modified with respect to the risk profile, availability of medical resources, and our experience. In this review, we summarize current pharmacological and interventional strategies used in the setting of STEMI and discuss potential benefits of novel dosing regimens and combinations of drugs and techniques.

Comparison of abciximab versus eptifibatide during percutaneous coronary intervention in ST-segment elevation myocardial infarction (from the HORIZONS-AMI trial)

There are limited safety and effectiveness data comparing glycoprotein IIb/IIIa inhibitors in the setting of primary percutaneous coronary intervention. In this substudy of the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial, the clinical and bleeding outcomes of eptifibatide versus abciximab were evaluated in patients with ST-segment elevation myocardial infarction who underwent percutaneous coronary intervention. Three-year clinical outcomes of patients in the heparin plus glycoprotein IIb/IIIa inhibitor arm were compared according to treatment with abciximab (n = 907) versus eptifibatide (n = 803). Adjudicated end points included major adverse cardiovascular events (MACEs; mortality, reinfarction, ischemia-driven target vessel revascularization, or stroke), major bleeding, and net adverse clinical events (MACEs or major bleeding). Propensity score matching was used to identify 1,342 matched cases (671 each in the abciximab and eptifibatide groups). Multivariate analysis was performed in the entire cohort and the propensity-matched groups. At 3-year follow-up, eptifibatide and abciximab resulted in nonsignificantly different rates of MACEs (18.3% vs 19.6%, hazard ratio [HR] 0.93, 95% confidence interval [CI] 0.74 to 1.16, p = 0.51), major bleeding (10.7% vs 11.9%, HR 0.90, 95% CI 0.67 to 1.19, p = 0.44), and net adverse clinical events (24.5% vs 25.5%, HR 0.96, 95% CI 0.79 to 1.17, p = 0.69). Similarly, at 3 years by multivariate analysis, there was no statistically significant difference between abciximab and eptifibatide for net adverse clinical events (HR 0.89, 95% CI 0.73 to 1.09, p = 0.27), MACEs (HR 0.96, 95% CI 0.77 to 1.20, p = 0.73), and major bleeding (HR 1.05, 95% CI 0.78 to 1.41, p = 0.75). The propensity-matched groups also had similar outcomes. In conclusion, abciximab and eptifibatide have comparable bleeding risks and clinical efficacy in primary percutaneous coronary intervention.

Microvascular effect of intracoronary eptifibatide in acute myocardial infarction

OBJECTIVES

In this prospective, randomized trial in patients with acute myocardial infarction (AMI) admitted for primary percutaneous coronary intervention (PPCI), loaded with 600 mg clopidogrel, we hypothesized that eptifibatide administered downstream of the coronary occlusion leads to a lower degree of microvascular obstruction compared with no additional eptifibatide.

METHODS

Fifty patients with AMI, loaded with 600 mg of clopidogrel at the first hospital contact, with occlusion of the left anterior descending artery (LAD), were randomized to an eptifibatide group (EG) or a control group (CG). In both groups, stenting was performed after thrombus aspiration. Microvascular reperfusion was assessed by angiography, electrocardiography, and transthoracic Doppler ultrasonography of the LAD.

RESULTS

TIMI myocardial perfusion grade 2-3 was not different between the EG (72%) and the CG (84%) (p = 0.31). ST segment resolution >70% was similarly detected in both groups (32 vs. 40%; p = 0.56). The mean diastolic deceleration time did not differ significantly between the CG (856.36 ± 397.88 ms) and the EG (935.72 ± 252.22 ms) (p = 0.41). Multivariate logistic regression revealed no significant influence of the treatment with eptifibatide on ST segment resolution (OR 0.47; 95% CI 0.11-2.10, p = 0.32), TIMI myocardial perfusion (OR 0.52; 95% CI 0.10-2.59, p = 0.42), and diastolic deceleration time (OR 0.21; 95% CI 0.03-1.51, p = 0.12).

CONCLUSIONS

In AMI patients loaded with 600 mg of clopidogrel undergoing PPCI, intracoronary administration of eptifibatide does not clearly improve microvascular obstruction.

Assessing the role of eptifibatide in patients with diffuse coronary disease undergoing drug-eluting stenting: the INtegrilin plus STenting to Avoid myocardial Necrosis Trial

BACKGROUND

The optimal antiplatelet regimen in elective patients undergoing complex percutaneous coronary interventions (PCIs) is uncertain. We aimed to assess the impact of glycoprotein IIb/IIIa (GpIIb/IIIa) inhibition with eptifibatide in clinically stable subjects with diffuse coronary lesions.

METHODS

Patients with stable coronary artery disease undergoing PCI by means of implantation of >33 mm of drug-eluting stent were single-blindedly randomized to heparin plus eptifibatide versus heparin alone. The primary end point was the rate of abnormal post-PCI creatine kinase-MB mass values. Secondary end points were major adverse cardiovascular events (MACEs) (ie, cardiac death, myocardial infarction, or urgent revascularization) and MACE plus bailout GpIIb/IIIa inhibitor use.

RESULTS

The study was stopped for slow enrollment and funding issues after including a total of 91 patients: 44 were randomized to heparin plus eptifibatide, and 47, to heparin alone. Analysis for the primary end point showed a trend toward lower rates of abnormal post-PCI creatine kinase-MB mass values in the heparin-plus-eptifibatide group (18 [41%]) versus the heparin-alone group (26 [55%], relative risk 0.74 [95% CI 0.48-1.15], P = .169). Similar nonstatistically significant trends were found for rates of MACE, their components, or MACE plus bailout GpIIb/IIIa inhibitors (all P > .05). Notably, heparin plus eptifibatide proved remarkably safe because major bleedings or minor bleeding was uncommon and nonsignificantly different in both groups (all P > .05).

CONCLUSIONS

Given its lack of statistical power, the INSTANT study cannot definitively provide evidence against or in favor of routine eptifibatide administration in stable patients undergoing implantation of multiple drug-eluting stent for diffuse coronary disease. However, the favorable trend evident for the primary end point warrants further larger randomized studies.

Treatment with tirofiban for acute coronary syndrome (ACS): a systematic review and network analysis

OBJECTIVE

To assess the efficacy of tirofiban in comparison to usual care or other GPIIb/IIIa antagonists (eptifibatide and abciximab). Results were analysed by drug administration with planned percutaneous coronary intervention (PCI) or as medical management without planned PCI, and separately for STEMI or NSTE ACS patients.

RESEARCH DESIGN AND METHODS

A systematic review was performed of randomized controlled trials of tirofiban, abciximab, eptifibatide or usual care given to patients with acute coronary syndrome. Nine databases were searched up to March 2010. Pair-wise meta-analysis was used to combine all available direct comparisons; indirect comparisons and network analysis were performed when this was not possible. The primary outcome was MACE (major adverse cardiac event).

RESULTS

The search yielded 8, 119 records and 50 trials were included (total number of patients = 52,958). Compared to usual care, high and medium-dose tirofiban (25 and 10 µg/kg/min) administered with planned PCI reduced MACE at 30 days for patients with STEMI (RR 0.67, 95% CI 0.45, 0.99; RR 0.28, 95% CI 0.10, 0.80), but was not effective as a medical management. Medium-dose tirofiban (10 µg/kg/min) administered with planned PCI or low dose (0.4 µg/kg/min) as medical management reduced the risk of MACE for patients with NSTE ACS (RR 0.39, 95% CI 0.21, 0.75; RR 0.58, 95% CI 0.41, 0.83) in comparison to usual care, but at the expense of increased thrombocytopenia (RR 3.26, 95% CI 1.31, 8.13). Evidence from RCTs and network analysis indicated tirofiban and abciximab were equally effective and safe. Comparing tirofiban and eptifibatide treatment by indirect and network analysis produced inconclusive results.

CONCLUSIONS

Tirofiban was more effective than usual care for STEMI and NSTE ACS patients receiving planned PCI, and NSTE ACS patients receiving medical management. Tirofiban and abciximab were equally effective. Comparisons of tirofiban and eptifibatide were inconclusive.

Contemporary use of glycoprotein IIb/IIIa inhibitors

Platelet glycoprotein IIb/IIIa inhibitors (GPI) are antithrombotic agents preventing the binding of fibrinogen to GP IIb/IIIa receptors. Thus, GPI interfere with interplatelet bridging mediated by fibrinogen. Currently, three generic GPI with different antithrombotic properties are available for intravenous administration: abciximab, eptifibatide, and tirofiban. The development of oral GPI was abandoned, whereas intravenous GPI were introduced in various clinical settings during the 1990s, yielding substantial benefit in the treatment of acute coronary syndromes, particularly during percutaneous coronary interventions. Results of the many randomised trials evidenced the efficacy of this drug class, though these trials were conducted prior to the emergence of modern oral antiplatelet therapy with efficient P2Y(12) inhibitors. Subsequent trials failed to consolidate the strongly favourable impression of GPI, and indications for their use have been more restricted in recent years. Nonetheless, GPI may still be beneficial during coronary interventions among high-risk patients including acute ST-elevation and non-ST-elevation myocardial infarctions, particularly in the absence of adequate pretreatment with oral antiplatelet drugs or when direct thrombin inhibitors are not utilised. Intracoronary GPI administration has been suggested as adjunctive therapy during primary percutaneous coronary intervention, and the results of larger ongoing trials are expected to elucidate its clinical potential. The present review outlines the key milestones of GPI development and provides an up-to-date overview of the clinical applicability of these drugs in the era of refined coronary stenting, potent antithrombotic drugs, and novel thrombin inhibiting agents.

Optimal use of platelet glycoprotein IIb/IIIa receptor antagonists in patients undergoing percutaneous coronary interventions

Discovery of the central role of platelets in the pathogenesis of acute coronary syndromes (ACS) and ischaemic complications of percutaneous coronary interventions (PCI) has led to the widespread use of oral and parenteral platelet inhibitors to treat these conditions. Glycoprotein (GP) IIb/IIIa (also known as α(IIb)β(3)) receptors on the surface of platelets play an essential role in platelet aggregation and serve as a key mediator in the formation of arterial thrombus. When activated, GP IIb/IIIa receptors bind to fibrinogen, which serves as the 'final common pathway' in platelet aggregation. Of the numerous agents developed for modulating platelet activity, intravenous platelet GP IIb/IIIa receptor antagonists are the most potent. There are four agents in clinical use, including abciximab, eptifibatide, tirofiban and lamifiban, although lamifiban is not approved for use in the US. While all agents block fibrinogen binding to GP IIb/IIIa, they do so by different mechanisms. Abciximab is a humanized form of a murine monoclonal antibody directed against GP IIb/IIIa, eptifibatide is a synthetic, cyclic heptapeptide that contains a lysine-glycine-aspartic acid (KGD) sequence that mimics the arginine-glycine-aspartic acid (RGD) sequence found on GP IIb/IIIa, tirofiban is a non-peptide antagonist derived by optimization of the tyrosine analogue that structurally mimicks the RGD-containing loop of the disintegrin echistatin, and lamifiban is a synthetic, non-cyclic, non-peptide, low-molecular-weight compound. In clinical trials, use of these agents reduces ischaemic adverse cardiovascular events in patients with ACS undergoing PCI, but at a cost of increased bleeding.

Quantitative analysis of the impact of total ischemic time on myocardial perfusion and clinical outcome in patients with ST-elevation myocardial infarction

Early reperfusion of the infarct-related coronary artery is an important issue in improvement of outcomes after ST-segment elevation myocardial infarction (STEMI). In this study, the clinical significance of total ischemic time on myocardial reperfusion and clinical outcomes was evaluated in patients with STEMI treated with primary percutaneous coronary intervention and thrombus aspiration and additional triple-antiplatelet therapy. Total ischemic time was defined as time from symptom onset to first intracoronary therapy (first balloon inflation or thrombus aspiration). All patients with STEMI treated with primary percutaneous coronary intervention with total ischemic times ≥30 minutes and <24 hours from 2005 to 2008 were selected. Ischemic times were available in 1,383 patients, of whom 18.4% presented with total ischemic times ≤2 hours, 31.2% >2 to 3 hours, 26.8% >3 to 5 hours, and 23.5% >5 hours. Increased ischemic time was associated with age, female gender, hypertension, and diabetes. Patients with total ischemic times <5 hours more often had myocardial blush grade 3 (40% to 45% vs 22%, p <0.001) and complete ST-segment resolution (55% to 60% vs 42%, p = 0.002) than their counterparts with total ischemic times >5 hours. In addition, patients with total ischemic times ≤5 hours had lower 30-day mortality (1.5% vs 4.0%, p = 0.032) than patients with total ischemic times >5 hours. In conclusion, in this contemporary cohort of patients with STEMI treated with primary percutaneous coronary intervention, triple-antiplatelet therapy, and thrombus aspiration, short ischemic time was associated with better myocardial reperfusion and decreased mortality. After a 5-hour period in which outcomes remain relatively stable, myocardial reperfusion becomes suboptimal and mortality increases.

Current antithrombotic agents for acute coronary syndromes: focus on bleeding risk

The formation of an intravascular thrombus underlies the clinical symptoms associated with acute coronary syndromes (ACS). Plaque rupture signals the recruitment and activation of platelets, initiation of the coagulation cascade, and generation of thrombin, resulting in the formation of a platelet-rich thrombus. Use of antithrombotic therapy, including antiplatelet and anticoagulant agents, is a crucial element in reducing the overall morbidity and mortality in patients with ACS. Current antiplatelet and anticoagulant therapies act on distinct sites in platelet activation pathways and the coagulation cascade, but because these agents target pathways necessary for protective hemostasis, their use increases the risk for bleeding complications. Previously, bleeding was considered an unavoidable side effect of ACS management with few clinical implications; however, bleeding has since been shown to be an independent predictor of short- and long-term mortality in patients with ACS. Therefore, the prevention of bleeding has become equally as important as the prevention of further ischemic events. Strategies to limit bleeding include bleeding risk stratification, appropriate dosing of antithrombotic drugs, use of the lowest dose of aspirin with proven efficacy, avoidance of combinations of antithrombotic agents unless for a proven indication, use of drugs proven to reduce the risk of bleeding, and choice of radial access over femoral access in case of invasive strategy. In this context, several novel therapeutic approaches are currently under clinical evaluation, including new antiplatelet agents, such as protease-activated receptor 1 antagonists, and new anticoagulants, such as direct-acting antagonists of factor Xa and factor IIa (thrombin). This review discusses antiplatelet and anticoagulant treatment strategies for the management of ACS, with a particular focus on their associated bleeding risks.

Efficacy and safety of unfractionated heparin plus glycoprotein IIb/IIIa inhibitors during revascularization for an acute coronary syndrome: a meta-analysis of randomized trials performed with stents and thienopyridines

BACKGROUND

Early studies of glycoprotein IIb/IIIa inhibitors (GPIs) demonstrated benefit during percutaneous coronary intervention for acute coronary syndromes (ACS). Since their introduction, the magnitude of benefit of GPIs has become unclear.

HYPOTHESIS

We hypothesized that adding a GPI to unfractionated heparin in ACS patients treated with stents and thienopyridines is beneficial.

METHODS

We searched the MEDLINE, Cochrane, and clinicaltrials.gov databases for randomized clinical trials that studied the use of GPIs during ACS. We required that patients be randomly assigned to unfractionated heparin plus a GPI versus unfractionated heparin plus placebo (or control). Additional inclusion criteria included the use of coronary stents and periprocedural thienopyridines. Outcomes were assessed at 30 days. Random effects DerSimonian-Laird summary risk ratios (RR) and 95% confidence intervals (CIs) were constructed.

RESULTS

Sixteen studies with 7611 patients were included. Myocardial infarction was 3.1% with GPI versus 4.4% with control (RR = 0.74; 95% CI, 0.59-0.94, P = 0.014); revascularization, 1.7% versus 2.7% (RR = 0.64; 95% CI, 0.46-0.89, P = 0.008); major bleeding, 2.5% versus 2.1% (RR = 1.21; 95% CI, 0.89-1.63, P = 0.22); minor bleeding, 5.5% versus 4.1% (RR = 1.37; 95% CI, 1.06-1.78, P = 0.016); and mortality, 2.2% versus 2.9% (RR = 0.79; 95% CI, 0.59-1.06, P = 0.12), respectively.

CONCLUSIONS

Among ACS patients treated with stents and thienopyridines, GPIs were associated with reduced myocardial infarction and revascularization. Minor, but not major bleeding was increased with GPIs. Mortality was similar between the groups. © 2011 Wiley Periodicals, Inc. Supporting information may be found in the online version of this article This work was supported by an unrestricted grant from the Florida Heart Research Institute, which had no role in the study design, data collection, analysis, or interpretation, manuscript writing, or decision to proceed with publication. Anthony A Bavry has received research support from Novartis Pharmaceuticals and serves as a contractor for American College of Cardiology Cardiosource. The other authors have no funding, financial relationships, or conflicts of interest to disclose.

Glycoprotein IIb-IIIa inhibitors

Platelets play a pivotal role in the pathogenesis of coronary artery disease and myocardial infarction. Therefore, great interests have been focused in the last decades on improvement in antiplatelet therapies, that currently are regarded as main pillars in the prevention and treatment of coronary artery disease, with special attention to glycoprotein IIb-IIIa (GP IIb-IIIa) receptors, that mediates the final stage of platelet activation. GP IIb-IIIa inhibitors, especially abciximab, have been shown to improve clinical outcome in patients undergoing primary angioplasty for STEMI. Upstream administration cannot routinely recommended, but may potentially be considered among high-risk patients within the first 4 h from symptoms onset. In case of periprocedural administration of antithrombotic therapy, Bivalirudin should be considered, especially in patients at high risk for bleeding complications. Among high-risk patients with acute coronary syndromes, an early invasive strategy with selective downstream administration of GP IIb-IIIa inhibitors is the strategy of choice, whereas bivalirudin should be considered in patients at high risk for bleeding complications. Among patients with unstable angina GP IIb-IIIa inhibitors should be considered only in case of evidence of intracoronary thrombus or in case of thrombotic complications (as provisional use). Further, randomized trials are certainly needed in the era of new oral antiplatelet therapies, and with strategies to prevent bleeding complications such as larger use of radial approach, mechanical closure devices, bivalirudin, or postprocedural protamine administration to promote early sheat removal.

The original sin committed in years two thousand

Contemporary treatment of ST segment elevation myocardial infarction requires the use of potent antithrombotic drugs. Glycoprotein IIb/IIIa inhibitors, especially abciximab, have been used diffusely in the last 10 years to help obtain procedural success and conversely to improve clinical outcome. However, the increased bleeding rate associated with this class of drugs is still a matter of concern. This editorial comments on the results of some recently published papers on these "old" drugs, with the auspice of looking at newer, safer drugs.

Abciximab as an adjunctive therapy for patients undergoing percutaneous coronary interventions

INTRODUCTION

Platelets play a central role in the pathophysiology of acute coronary syndromes (ACS) and activation of platelet glycoprotein (GP) IIb/IIIa receptor is critical to platelet aggregation. Abciximab, a human murine chimeric antibody to the GPIIb/IIIa receptor, is an important biological therapy in the management of patients presenting with ACS.

AREAS COVERED

The objective of this review is to define the role of abciximab in the management of ACS by interpreting the available data from randomized clinical trials using abciximab in various clinical scenarios, particularly in percutaneous coronary intervention (PCI). We also review different modes of delivery and describe the adverse effects of abciximab including thrombocytopenia. Where possible, we attempt to compare abciximab to the other available GPIIb/IIIa inhibitors. We hope the reader will gain a better understanding of the benefits and risks of abciximab and the important role it has in the management of cardiology patients.

EXPERT OPINION

Abciximab was a breakthrough drug in the management of high risk ACS patients undergoing PCI. However, with newer available therapies and improvement in PCI technology, dose and delivery of this drug have evolved as we try to extract maximum benefit while minimizing the adverse effects associated with it.