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Liu X, He W, Li M, Yang J, Huang J, Kong W, Guo C, Hu J, Liu S, Yang D, Song J, Peng Z, Li L, Tian Y, Zi W, Yue C, Li F. Predictors of outcome in large vessel occlusion stroke patients with intravenous tirofiban treatment: a post hoc analysis of the RESCUE BT clinical trial. BMC Neurol 2024; 24:227. [PMID: 38956505 PMCID: PMC11218210 DOI: 10.1186/s12883-024-03733-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 06/17/2024] [Indexed: 07/04/2024] Open
Abstract
OBJECTIVE The aim of this study was to investigate the factors influencing good outcomes in patients receiving only intravenous tirofiban with endovascular thrombectomy for large vessel occlusion stroke. METHODS Post hoc exploratory analysis using the RESCUE BT trial identified consecutive patients who received intravenous tirofiban with endovascular thrombectomy for large vessel occlusion stroke in 55 comprehensive stroke centers from October 2018 to January 2022 in China. RESULTS A total of 521 patients received intravenous tirofiban, 253 of whom achieved a good 90-day outcome (modified Rankin Scale [mRS] 0-2). Younger age (adjusted odds ratio [aOR]: 0.965, 95% confidence interval [CI]: 0.947-0.982; p < 0.001), lower serum glucose (aOR: 0.865, 95%CI: 0.807-0.928; p < 0.001), lower baseline National Institutes of Health Stroke Scale (NIHSS) score (aOR: 0.907, 95%CI: 0.869-0.947; p < 0.001), fewer total passes (aOR: 0.791, 95%CI: 0.665-0.939; p = 0.008), shorter punctures to recanalization time (aOR: 0.995, 95%CI:0.991-0.999; p = 0.017), and modified Thrombolysis in Cerebral Infarction (mTICI) score 2b to 3 (aOR: 8.330, 95%CI: 2.705-25.653; p < 0.001) were independent predictors of good outcomes after intravenous tirofiban with endovascular thrombectomy for large vessel occlusion stroke. CONCLUSION Younger age, lower serum glucose level, lower baseline NIHSS score, fewer total passes, shorter punctures to recanalization time, and mTICI scores of 2b to 3 were independent predictors of good outcomes after intravenous tirofiban with endovascular thrombectomy for large vessel occlusion stroke. CHINESE CLINICAL TRIAL REGISTRY IDENTIFIER ChiCTR-IOR-17014167.
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Affiliation(s)
- Xiang Liu
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China
| | - Wencheng He
- Department of Neurology, Guangxi Guiping People's Hospital, Guiping, Guangxi, China
| | - Meiqiong Li
- Department of Neurology, Guangxi Guiping People's Hospital, Guiping, Guangxi, China
| | - Jie Yang
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China
| | - Jiacheng Huang
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China
| | - Weilin Kong
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China
| | - Changwei Guo
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China
| | - Jinrong Hu
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China
| | - Shuai Liu
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China
| | - Dahong Yang
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China
| | - Jiaxing Song
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China
| | - Zhouzhou Peng
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China
| | - Linyu Li
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China
| | - Yan Tian
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China
| | - Wenjie Zi
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China
| | - Chengsong Yue
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China.
| | - Fengli Li
- Department of Neurology, The Second Affiliated Hospital, Xinqiao Hospital, Army Medical University, Third Military Medical University, Chongqing, 400037, China.
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Wang L, Zeng Y, Zhou L, Xu P, Guo X, Xie Y, Cai J, Pan M, Tang J, Gong Q, Su R, Liu Y, Lou Y. Cost-effectiveness of tirofiban for acute ischemic stroke without large or medium-sized vessel occlusion: A Markov modelling analysis from the Chinese and United States perspectives. PLoS One 2024; 19:e0297939. [PMID: 38363737 PMCID: PMC10871502 DOI: 10.1371/journal.pone.0297939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/14/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND The RESCUE BT2 trial recently showcased the efficacy of tirofiban in treating acute ischemic stroke (AIS) without large or medium-sized vessel occlusion. To further assess the value of tirofiban from the perspectives of Chinese and US healthcare system, a study was conducted to evaluate its cost-effectiveness. METHODS A hybrid model, integrating a short-term decision tree with a long-term Markov model, was developed to assess cost-effectiveness between tirofiban and aspirin for stroke patients without large or medium-sized vessel occlusion. Efficacy data for tirofiban was sourced from the RESCUE BT2 trial, while cost information was derived from published papers. Outcomes measured included respective cost, effectiveness, and incremental cost-effectiveness ratio (ICER). We conducted a one-way sensitivity analysis to assess the robustness of the results. Additionally, we performed probabilistic sensitivity analysis (PSA) through 10,000 Monte Carlo simulations to evaluate the uncertainties associated with the results. RESULTS The study revealed that tirofiban treatment in AIS patients without large or medium-sized vessel occlusion led to a considerable reduction of 2141 Chinese Yuan (CNY) in total cost, along with a lifetime gain of 0.14 quality-adjusted life years (QALYs). In the US settings, tirofiban also exhibited a lower cost ($197,055 versus $201,984) and higher effectiveness (4.15 QALYs versus 4.06 QALYs) compared to aspirin. One-way sensitivity analysis revealed that post-stroke care costs and stroke utility had the greatest impact on ICER fluctuation in both Chinese and US settings. However, these variations did not exceed the willingness-to-pay threshold. PSA demonstrated tirofiban's superior acceptability over aspirin in over 95% of potential scenarios. CONCLUSION Tirofiban treatment for AIS without large or medium-sized vessel occlusion appeared dominant compared to aspirin in both China and the US.
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Affiliation(s)
- Li Wang
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Yuhong Zeng
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, People’s Republic of China
- Evidence-based Medicine and Clinical Epidemiology Center, Army Medical University (Third Military Medical University), Chongqing, People’s Republic of China
| | - Limei Zhou
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Ping Xu
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Xianbin Guo
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Yu Xie
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Junxiu Cai
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Min Pan
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Jie Tang
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Qingtao Gong
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Rong Su
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Yan Liu
- Department of Neurology, Zigong Third People’s Hospital, Zigong, China
| | - Yake Lou
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Lu WZ, Lin HA, Hou SK, Bai CH, Lin SF. Efficacy and safety of tirofiban in patients with acute ischemic stroke treated with endovascular thrombectomy: A frequentist and Bayesian meta-analysis. Vascul Pharmacol 2023; 153:107244. [PMID: 37992511 DOI: 10.1016/j.vph.2023.107244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/10/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Tirofiban is an antiplatelet treatment approved for acute coronary syndrome, but it has not been rigorously evaluated for efficacy and safety in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT). METHODS Electronic databases were systematically searched for studies conducted from January 1, 2015, to July 31, 2021, that evaluated tirofiban administration for patients with AIS treated with EVT in comparison with control. Risk ratios (RRs) and confidence intervals (CIs) were estimated for favorable functional outcomes (FFOs), mortality, and symptomatic intracranial hemorrhage (SICH), each 90 days after AIS. Bayesian hierarchical modeling was performed to obtain posterior RR and its 95% highest posterior density (HPD) for validation. RESULTS Compared with controls, tirofiban users exhibited increased FFOs (RR, 1.18; 95% CI, 1.08-1.30), decreased mortality (RR, 0.77; 95% CI, 0.64-0.92), and no difference in SICH (RR, 0.97; 95% CI, 0.77-1.23). Tirofiban users in the postbolus infusion subgroup exhibited increased FFOs (RR, 1.20; 95% CI, 1.07-1.35), decreased mortality (RR, 0.71; 95% CI, 0.58-0.88), and no increase in SICH (RR, 0.97; 95% CI, 0.72-1.29). The bolus-only subgroup showed no differences in FFO, mortality, or SICH between the tirofiban and control groups. Consistent results were obtained for posterior density of FFO (posterior RR, 1.20; 95% HPD, 1.06-1.34), mortality (posterior RR, 0.77; 95% HPD, 0.63-0.92), and SICH (posterior RR, 0.98; 95% HPD, 0.71-1.26). CONCLUSION For patients with AIS treated with EVT, tirofiban improved FFOs, decreased mortality, and did not increase SICH compared with controls; postbolus infusion for administering tirofiban was more favored than the bolus-only regimen.
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Affiliation(s)
- Wei-Zhen Lu
- Department of Emergency Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan
| | - Hui-An Lin
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Sen-Kuang Hou
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chyi-Huey Bai
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan; Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Sheng-Feng Lin
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan; School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan; Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Gawaz M, Geisler T, Borst O. Current concepts and novel targets for antiplatelet therapy. Nat Rev Cardiol 2023; 20:583-599. [PMID: 37016032 DOI: 10.1038/s41569-023-00854-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 04/06/2023]
Abstract
Platelets have a crucial role in haemostasis and atherothrombosis. Pharmacological control of platelet hyper-reactivity has become a cornerstone in the prevention of thrombo-ischaemic complications in atherosclerotic diseases. Current antiplatelet therapies substantially improve clinical outcomes in patients with coronary artery disease, but at the cost of increased risk of bleeding. Beyond their role in thrombosis, platelets are known to regulate inflammatory (thrombo-inflammatory) and microcirculatory pathways. Therefore, controlling platelet hyper-reactivity might have implications for both tissue inflammation (myocardial ischaemia) and vascular inflammation (vulnerable plaque formation) to prevent atherosclerosis. In this Review, we summarize the pathophysiological role of platelets in acute myocardial ischaemia, vascular inflammation and atherosclerotic progression. Furthermore, we highlight current clinical concepts of antiplatelet therapy that have contributed to improving patient care and have facilitated more individualized therapy. Finally, we discuss novel therapeutic targets and compounds for antiplatelet therapy that are currently in preclinical development, some of which have a more favourable safety profile than currently approved drugs with regard to bleeding risk. These novel antiplatelet targets might offer new strategies to treat cardiovascular disease.
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Affiliation(s)
- Meinrad Gawaz
- Department of Cardiology and Angiology, Eberhard Karls University of Tübingen, Tübingen, Germany.
| | - Tobias Geisler
- Department of Cardiology and Angiology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Oliver Borst
- Department of Cardiology and Angiology, Eberhard Karls University of Tübingen, Tübingen, Germany
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Jiménez-Rodríguez GM, Carmona-Levario P, Ayón-Martínez JA, Gasecka A, Juárez-Orozco LE, Reyes-Ortega A, Espinosa-González P, Altamirano-Solorzano GA, Eid-Lidt G. Severe Acute Thrombocytopenia After Treatment with Tirofiban: A Case Series Approach. Interv Cardiol 2023; 18:e15. [PMID: 37398876 PMCID: PMC10311402 DOI: 10.15420/icr.2022.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/23/2022] [Indexed: 07/04/2023] Open
Abstract
Glycoprotein IIb/IIIa inhibitors are an adjuvant therapy for the treatment of patients with acute coronary syndromes. The main adverse reactions are bleeding and thrombocytopenia in 1-2% of cases. A 66-year-old woman arrived at the emergency department with ST-elevation MI. The catheterisation lab was busy, so she received thrombolytic therapy. Coronary angiography revealed a 90% stenosis in the middle segment of the left anterior descending artery and Thrombolysis in MI 2 flow. Subsequent percutaneous coronary intervention showed abundant thrombus and a coronary dissection and it was necessary to insert five drug-eluting stents. Non-fractionated heparin and a tirofiban infusion were used. After the percutaneous coronary intervention, she developed severe thrombocytopenia, haematuria and gingivorrhagia, for which infusion of tirofiban was suspended. In follow-up, no major bleeding or subsequent haemorrhagic complications were identified. It is crucial to distinguish between heparin-induced thrombocytopenia and thrombocytopenia caused by other drugs. A high level of suspicion should be employed in these cases.
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Affiliation(s)
| | - Patricia Carmona-Levario
- Interventional Cardiology Department, National Institute of Cardiology Ignacio ChávezMexico City, Mexico
| | - José-Alberto Ayón-Martínez
- Interventional Cardiology Department, National Institute of Cardiology Ignacio ChávezMexico City, Mexico
| | - Aleksandra Gasecka
- Department of Cardiology of the Medical University of WarsawWarsaw, Poland
| | | | - Antonio Reyes-Ortega
- Cardiology Department, National Institute of Cardiology Ignacio ChávezMexico City, Mexico
| | | | | | - Guering Eid-Lidt
- Interventional Cardiology Department, National Institute of Cardiology Ignacio ChávezMexico City, Mexico
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Tralhão A. Parenteral antiplatelet therapy in acute myocardial infarction complicated by cardiogenic shock - A field still worthy of future randomized trials? Rev Port Cardiol 2023; 42:121-123. [PMID: 36115802 DOI: 10.1016/j.repc.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- António Tralhão
- Cardiac Intensive Care Unit, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, EPE, Carnaxide, Portugal.
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Tralhão A. WITHDRAWN: Parenteral antiplatelet therapy in acute myocardial infarction complicated by cardiogenic shock - A field still needing future randomized trials? Rev Port Cardiol 2022:S0870-2551(22)00520-0. [PMID: 36526133 DOI: 10.1016/j.repc.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The Publisher regrets that this article is an accidental duplication of an article that has already been published, 10.1016/j.repc.2022.08.010. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
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Affiliation(s)
- António Tralhão
- Cardiac Intensive Care Unit, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, EPE, Carnaxide, Portugal.
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8
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Comparison of Ischemic and Bleeding Events Between Short-Duration Versus Long-Duration Tirofiban Regimens in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention. J Cardiovasc Pharmacol 2022; 80:56-61. [PMID: 35503989 DOI: 10.1097/fjc.0000000000001289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/27/2022] [Indexed: 11/26/2022]
Abstract
ABSTRACT Tirofiban has been used historically as a bridge to platelet inhibition with clopidogrel in ST-segment myocardial infarction (STEMI) during percutaneous coronary intervention (PCI) to prevent stent thrombosis. However, ticagrelor and prasugrel reach similar levels of platelet inhibition at 30 minutes to that of clopidogrel at 6 hours, challenging the need for long-duration tirofiban. This 1-year, retrospective cohort study compared ischemic and bleeding outcomes of short-duration versus long-duration tirofiban regimens in patients with STEMI who received ticagrelor or prasugrel at the time of PCI. The primary outcome was major adverse cardiovascular events (MACEs) including cardiovascular mortality, recurrent myocardial infarction, urgent target vessel revascularization, or stroke. Secondary outcomes included individual MACE, all-cause mortality, bleeding events defined by the International Society on Thrombosis and Hemostasis, thirty-day readmissions for MACE and bleeding, and tirofiban pharmacy cost. A total of 283 charts were reviewed and 177 included (short duration n = 57; long duration n = 120). MACE rates were similar between short-duration and long-duration groups (0 [0%] vs. 5 [4.2%]; P = 0.18), including 4 cardiovascular deaths and 1 recurrent myocardial infarction. Bleeding event rates were also similar in short-duration versus long-duration groups including major bleeds (2 [3.5%] vs. 2 [1.7%]; P = 0.60) and clinically relevant nonmajor bleeds (3 [5.3%] vs. 9 [7.5%]; P = 0.75). Cost analysis indicated lower pharmacy cost with the short-duration group. In this cohort of patients with STEMI receiving a fast-acting P2Y12 inhibitor, the length of tirofiban infusion did not affect ischemic or bleeding outcomes, yet short-duration regimens were lower cost.
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Heramvand N, Masyuk M, Muessig JM, Nia AM, Karathanos A, Polzin A, Valgimigli M, Gurbel PA, Tantry US, Kelm M, Jung C. Pharmacosimulation of delays and interruptions during administration of tirofiban: a systematic comparison between EU and US dosage regimens. J Thromb Thrombolysis 2022; 54:301-308. [PMID: 35482154 PMCID: PMC9363357 DOI: 10.1007/s11239-022-02654-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 12/01/2022]
Abstract
Tirofiban is a glycoproteine (GP) IIb/IIIa receptor antagonist, which inhibits platelet-platelet aggregation and is a potential adjunctive antithrombotic treatment in patients with acute coronary syndromes (ACS) or high-risk percutaneous coronary interventions (PCI). It is administered intravenously as a bolus followed by continuous infusion. However, the dosage recommendations in the United States (US) and European Union (EU) differ considerably. Furthermore, in routine clinical practice, deviations from the recommendations may occur. The objective of the present study was to investigate the impact of different alterations on tirofiban plasma concentrations in US and EU administration regimens and to give suggestions for delay management in clinical practice. We therefore mathematically simulated the effects of different bolus-infusion delays and infusion interruptions in different scenarios according to the renal function. Here, we provide a systematic assessment of concentration patterns of tirofiban in the US versus EU dosage regimens. We show that differences between the two regimens have important effects on plasma drug levels. Furthermore, we demonstrate that deviations from the proper administration mode affect the concentration of tirofiban. Additionally, we calculated the optimal dosage of a second bolus to rapidly restore the initial concentration without causing overdosage. In conclusion, differences in tirofiban dosing regimens between the U.S and EU and potential infusion interruptions have important effects on drug levels that may impact on degrees of platelet inhibition and thus antithrombotic effects. Thus, the findings of our modelling studies may help to explain differences in clinical outcomes observed in previous clinical trials on tirofiban.
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Affiliation(s)
- Nadia Heramvand
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Maryna Masyuk
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Johanna M Muessig
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Amir M Nia
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Athanasios Karathanos
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Amin Polzin
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marco Valgimigli
- Cardiocentro Ticino, Lugano and University of Bern, Bern, Switzerland
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Malte Kelm
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.,CARID: Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | - Christian Jung
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
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Ma Y, Jia C, Zhang T, Feng Y, Chen X, Zhao W. Safety and efficacy of intravenous tirofiban for stent-assisted coiling in acutely ruptured intracranial aneurysms: A single center experience. Interv Neuroradiol 2021; 28:476-481. [PMID: 34515564 PMCID: PMC9326857 DOI: 10.1177/15910199211042463] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There have been few reports on the use of tirofiban in ruptured intracranial aneurysms and the results were conflicting. However, the safety and efficacy of optimal dosage and the reasonable treatment course of tirofiban have not been determined. OBJECTIVE To determine the safety and efficacy of a new protocol for its prophylactic tirofiban application during the endovascular treatment of ruptured intracranial aneurysms with no oral antiplatelet medications. METHODS This retrospective study was based on 105 patients with ruptured aneurysms who underwent stent-assisted coiling at our institution between August 2017 and July 2020. Intravenous tirofiban was administered to patients after stent deployment. Tirofiban was administered as an intravenous bolus (5 µg/kg) over a 3 min period immediately after stent deployment, followed by a 0.06-0.08 µg/kg/min maintenance infusion for 12-24 h. Dual oral antiplatelet therapy was overlapped with half the tirofiban dose 2 h before the cessation of the tirofiban infusion. Cases of intracranial hemorrhage or thromboembolism were recorded. RESULTS This study included a total of 105 patients with ruptured intracranial aneurysms, who underwent stent-assisted coiling. In terms of clinical severity, a presenting Hunt-Hess clinical-grade I was observed in 47 (44.8%) cases, grade II in 19 (18.1%) cases, grade III in 30 (28.6%) cases, grade IV in 6 (5.6%) cases, and grade V in 3 (2.9%) cases. None of the patients showed a newly developed tirofiban-related intracerebral hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage, or ventriculostomy-related hemorrhage. There were 3 (2.8%) patients who had thromboembolic complications. CONCLUSIONS We have determined a new protocol for prophylactic intraoperative tirofiban during the endovascular treatment of ruptured intracranial aneurysms with no oral antiplatelet medications. In our study, tirofiban showed a low risk of hemorrhagic or thromboembolic complications. Tirofiban appears to be a safe and alternative during the stent-assisted coiling of ruptured intracranial aneurysms.
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Affiliation(s)
- Yihui Ma
- Department of Neurosurgery, 89674Zhongnan Hospital of Wuhan University, China
| | - Chenguang Jia
- Department of Neurosurgery, 89674Zhongnan Hospital of Wuhan University, China
| | - Tingbao Zhang
- Department of Neurosurgery, 89674Zhongnan Hospital of Wuhan University, China
| | - Yu Feng
- Department of Neurosurgery, 89674Zhongnan Hospital of Wuhan University, China
| | - Xinjun Chen
- Department of Neurosurgery, 89674Zhongnan Hospital of Wuhan University, China
| | - Wenyuan Zhao
- Department of Neurosurgery, 89674Zhongnan Hospital of Wuhan University, China
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Nicolau JC, Feitosa Filho GS, Petriz JL, Furtado RHDM, Précoma DB, Lemke W, Lopes RD, Timerman A, Marin Neto JA, Bezerra Neto L, Gomes BFDO, Santos ECL, Piegas LS, Soeiro ADM, Negri AJDA, Franci A, Markman Filho B, Baccaro BM, Montenegro CEL, Rochitte CE, Barbosa CJDG, Virgens CMBD, Stefanini E, Manenti ERF, Lima FG, Monteiro Júnior FDC, Correa Filho H, Pena HPM, Pinto IMF, Falcão JLDAA, Sena JP, Peixoto JM, Souza JAD, Silva LSD, Maia LN, Ohe LN, Baracioli LM, Dallan LADO, Dallan LAP, Mattos LAPE, Bodanese LC, Ritt LEF, Canesin MF, Rivas MBDS, Franken M, Magalhães MJG, Oliveira Júnior MTD, Filgueiras Filho NM, Dutra OP, Coelho OR, Leães PE, Rossi PRF, Soares PR, Lemos Neto PA, Farsky PS, Cavalcanti RRC, Alves RJ, Kalil RAK, Esporcatte R, Marino RL, Giraldez RRCV, Meneghelo RS, Lima RDSL, Ramos RF, Falcão SNDRS, Dalçóquio TF, Lemke VDMG, Chalela WA, Mathias Júnior W. Brazilian Society of Cardiology Guidelines on Unstable Angina and Acute Myocardial Infarction without ST-Segment Elevation - 2021. Arq Bras Cardiol 2021; 117:181-264. [PMID: 34320090 PMCID: PMC8294740 DOI: 10.36660/abc.20210180] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- José Carlos Nicolau
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Gilson Soares Feitosa Filho
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Centro Universitário de Tecnologia e Ciência (UniFTC), Salvador, BA - Brasil
| | - João Luiz Petriz
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
| | | | | | - Walmor Lemke
- Clínica Cardiocare, Curitiba, PR - Brasil
- Hospital das Nações, Curitiba, PR - Brasil
| | | | - Ari Timerman
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | - José A Marin Neto
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, SP - Brasil
| | | | - Bruno Ferraz de Oliveira Gomes
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | - Carlos Eduardo Rochitte
- Hospital do Coração (HCor), São Paulo, SP - Brasil
- Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Edson Stefanini
- Escola Paulista de Medicina da Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | | | - Felipe Gallego Lima
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - José Maria Peixoto
- Universidade José do Rosário Vellano (UNIFENAS), Belo Horizonte, MG - Brasil
| | - Juliana Ascenção de Souza
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Lilia Nigro Maia
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP - Brasil
| | | | - Luciano Moreira Baracioli
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luís Alberto de Oliveira Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luis Augusto Palma Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Luiz Carlos Bodanese
- Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | | | - Marcelo Bueno da Silva Rivas
- Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Múcio Tavares de Oliveira Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Nivaldo Menezes Filgueiras Filho
- Universidade do Estado da Bahia (UNEB), Salvador, BA - Brasil
- Universidade Salvador (UNIFACS), Salvador, BA - Brasil
- Hospital EMEC, Salvador, BA - Brasil
| | - Oscar Pereira Dutra
- Instituto de Cardiologia - Fundação Universitária de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | - Otávio Rizzi Coelho
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | | | | | - Paulo Rogério Soares
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - Roberto Esporcatte
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Talia Falcão Dalçóquio
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - William Azem Chalela
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Wilson Mathias Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
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12
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Xiang Y, Zhao H, Ding C, Chen H, Wang D, Liu A. The Prophylactic Use of Tirofiban versus Oral Antiplatelet Medications in Stent-Assisted Coiling of Intracranial Aneurysms: A Meta-analysis. AJNR Am J Neuroradiol 2021; 42:713-719. [PMID: 33707284 DOI: 10.3174/ajnr.a6996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/02/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND The protocol for optimal antiplatelet therapy to prevent thromboembolic and hemorrhagic complications in patients with cerebral aneurysms using an endovascular approach is not clear. PURPOSE Our study analyzed the safety and efficacy of prophylactic tirofiban administration compared with oral antiplatelet drug therapy. DATA SOURCES We used the PubMed, EMBASE, MEDLINE, and Cochrane library data bases. STUDY SELECTION Our study consisted of all case series with >5 patients that reported treatment-related outcomes of patients undergoing endovascular procedures pretreated with tirofiban or oral antiplatelet drug therapy. DATA ANALYSIS Random effects or fixed effects meta-analysis was used to pool the cumulative rate of complications, perioperative mortality, and good clinical outcomes. DATA SYNTHESIS Fifteen studies with 1981 patients were registered. Thromboembolic complications were significantly lower in the tirofiban group (3.6%; 95% CI, 1.9%-5.8%) compared with the dual-antiplatelet therapy group (8.5%, 95% CI, 4.5%-13%; P = .04). Pretreatment with tirofiban did not remarkably increase the rate of hemorrhagic complications (3.5%; 95% CI, 1.8%-5.6%) compared with dual-antiplatelet therapy (5.1%; 95% CI, 2.6%-8.5%; P = .371). There was a trend toward lower perioperative mortality with tirofiban (0.8%; 95% CI, 0.2%-1.6%) compared with dual-antiplatelet therapy (1.2%; 95% CI, 0.7%-2.0%; P = .412). There was no significant difference in the safety and efficacy between the tirofiban bolus plus drip and drip alone. LIMITATIONS The limitations are selection and publication biases. CONCLUSIONS Prophylactic therapy with tirofiban resulted in significantly lower rates of thromboembolic complications with no increase in hemorrhagic events or mortality than the prophylactic use of dual-antiplatelet therapy.
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Affiliation(s)
- Y Xiang
- From the Departments of Pharmacy (Y.X., A.L.)
| | | | - C Ding
- Department of Pharmacy (C.D.), Affiliated Hospital of Weifang Medical University, Weifang Shandong, China
| | - H Chen
- Department of Pharmacy (H.C.), Special Care Hospital of Jinan City, Jinan, Shandong, China
| | - D Wang
- Neurosurgery (D.W.), Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - A Liu
- From the Departments of Pharmacy (Y.X., A.L.)
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13
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Revilla-Martí P, Linares-Vicente JA, Martínez Labuena A, Jiménez Melo O, Morlanes Gracia P, Meseguer González D, Lukic A, Simó Sánchez B, Ruiz Arroyo JR. Efficacy and safety of abciximab versus tirofiban in addition to ticagrelor in STEMI patients undergoing primary percutaneous intervention. Platelets 2021; 33:265-272. [PMID: 33560898 DOI: 10.1080/09537104.2021.1881953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Platelet glycoprotein IIb/IIIa inhibitors (GPIs) have been part of the adjuvant treatment of acute coronary syndrome for years. However, real-life data regarding the efficacy and safety of GPIs under the current indications are lacking in the setting of potent platelet inhibition. The objectives were to assess the efficacy and safety of abciximab versus tirofiban in patients with ST-elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) and pretreated with ticagrelor, and to identify independent predictor factors of efficacy, bleeding and platelet drop. Three hundred sixty-two patients were divided by GPI administered. Clinical, laboratory, angiographic and outcome characteristics were compared. The primary objective was a composite efficacy endpoint (death from any cause, nonfatal myocardial infarction and nonfatal stroke) at 30 days. The secondary objectives were its individual components, safety (bleeding) and the impact on platelet count during hospital stay. The composite efficacy endpoint was similar in the abciximab and tirofiban groups (6.1% vs 7.3%; p = .632). There were also no differences in cardiovascular death (2.5% vs 2.4%; p = .958), nonfatal myocardial infarction (3% vs 4.3%; p = .521) and nonfatal stroke (0.5% vs 1.8%; p = .332). Tirofiban administration was associated with a higher incidence of bleeding (11.6% vs 22%; p = .008) with no differences in BARC ≥ 3b bleeding (3.6 vs 2.5%; p = .760). In STEMI patients undergoing PPCI with ticagrelor, abciximab and tirofiban had similar rates in the composite efficacy endpoint at 30 days. The 30-day bleeding rate was significantly higher in the tirofiban group. Tirofiban administration was an independent predictor of both bleeding and platelet count drop.
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Affiliation(s)
- Pablo Revilla-Martí
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | | | - Ana Martínez Labuena
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | - Octavio Jiménez Melo
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | - Paula Morlanes Gracia
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | | | - Antonela Lukic
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | - Borja Simó Sánchez
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | - Jose R Ruiz Arroyo
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
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14
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Yeh YT, Hsu JC, Liao PC, Li AH, Liu YH, Chen KC, Chuang W, Ke SR, Chiu YW, Wu YW. Modulators of Mortality Benefit From Peri-Angioplasty Adjunctive Tirofiban in Patients With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Circ J 2021; 85:166-174. [PMID: 33441492 DOI: 10.1253/circj.cj-20-0228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Studies investigating the modulators of mortality benefit conferred by peri-angioplasty glycoprotein IIb/IIIa inhibitors in ST-elevation myocardial infarction (STEMI) are still lacking.Methods and Results:A prospective database (n=1,025) of consecutive cases undergoing primary percutaneous coronary intervention for STEMI was retrospectively analyzed. For patients in Killip class I, II or III, IV, the multivariate-adjusted hazard ratios of 30-day all-cause mortality associated with adjunctive tirofiban were 3.873 (95% CI 0.504-29.745; P=0.193), 0.550 (95% CI 0.188-1.609; P=0.275), and 0.264 (95% CI 0.099-0.704; P=0.008), respectively. The P value for a linear trend was 0.032. Patients who had a body mass index (BMI) within 22.9-25.0 kg/m2had a significant benefit from tirofiban (adjusted HR 0.344; 95% CI 0.145-0.814; P=0.015) compared to other BMI groups. The P value for a quadratic trend was 0.012. A novel Killip-BMI score (KBS = 2.5 × Killip category - | BMI - 24 |) was calculated to select the beneficial population. A KBS ≥2 was associated with significant mortality benefit, whereas a KBS <0 predicted increased 30-day mortality with tirofiban use. CONCLUSIONS Survival benefit from peri-angioplasty tirofiban therapy for STEMI was positively correlated with the Killip class. Tirofiban should be used cautiously in either underweight or overweight patients. The novel KBS used in this study can guide peri-angioplasty use of adjunctive tirofiban in patients with STEMI undergoing primary angioplasty.
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Affiliation(s)
- Yen-Ting Yeh
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Jung-Chung Hsu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Pen-Chih Liao
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Ai-Hsien Li
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Yuan-Hung Liu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Kuo-Chin Chen
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Wenpo Chuang
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Shin-Rong Ke
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Yu-Wei Chiu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital.,Department of Computer Science and Engineering, Yuan Ze University
| | - Yen-Wen Wu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital.,Department of Nuclear Medicine, Far Eastern Memorial Hospital.,National Yang-Ming University School of Medicine.,Department of Nuclear Medicine and Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine
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15
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Efficacy and Safety of Abbreviated Eptifibatide Treatment in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Am J Cardiol 2021; 139:15-21. [PMID: 33065082 DOI: 10.1016/j.amjcard.2020.09.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/27/2020] [Accepted: 09/30/2020] [Indexed: 01/05/2023]
Abstract
The glycoprotein IIb/IIIa inhibitor eptifibatide, administered as bolus followed by infusion, is an adjunctive antithrombotic treatment during primary percutaneous coronary intervention (PCI) in selected patients with ST-segment elevation myocardial infarction (STEMI). Whether both bolus and infusion are necessary to improve outcomes is unknown. We hypothesized that primary PCI with eptifibatide bolus only is non-inferior to the conventional treatment (bolus and infusion) with regard to infarct size, while reducing bleeding complications. We analyzed 720 consecutive STEMI patients receiving eptifibatide bolus only or conventional treatment in an observational case-control study utilizing propensity score matching of clinical and intervention-specific confounders. Infarct size was estimated based on myocardial bound creatine kinase, creatine kinase (CK), and CK area under the curve values, with a prespecified non-inferiority margin of 20%. Major bleeding was defined as type 2, 3, or 5 on the Bleeding Academic Research Consortium classification. Eptifibatide bolus only was administered to 147 patients (20%), which were matched 1:1 to patients receiving conventional treatment. Based on peak myocardial bound creatine kinase, CK and CK area under the curve values, infarct size was -8.4% (95% CI [-31.2%, 14.4%]), -11.6% (95% CI [-33.5%, 10.3%]), and -13.9% (95% CI [-34.1%, 6.2%]) after eptifibatide bolus, respectively, reaching prespecified noninferiority compared with conventional treatment. Bolus treatment significantly reduced major bleeding complications (OR 0.48, 95% CI [0.30, 0.79]). In conclusion, eptifibatide given as abbreviated bolus only to selected STEMI patients who underwent primary PCI was noninferior regarding infarct size and resulted in less bleeding complications compared with conventional bolus and infusion treatment.
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16
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Wu Q, Shao Q, Li L, Liang X, Chang K, Li T, He Y. Prophylactic administration of tirofiban for preventing thromboembolic events in flow diversion treatment of intracranial aneurysms. J Neurointerv Surg 2020; 13:835-840. [PMID: 33199539 DOI: 10.1136/neurintsurg-2020-016878] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/21/2020] [Accepted: 10/23/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Flow diverter (FD) is widely used in the treatment of intracranial aneurysms. However, thromboembolic events (TEs) continue to be the major complications during the periprocedural phase. To evaluate the safety and efficacy of the prophylactic use of tirofiban, combined with the conventional dual antiplatelet therapy (DAT), as a new antiplatelet protocol in patients with intracranial aneurysms treated with FDs. METHODS At least 3-5 days before the procedure, daily DAT were administrated to the patients. Tirofiban was administered as an intravenous bolus (5 µg/kg) over a 3 min period during or immediately after FD deployment, followed by a 0.05 µg/kg/min maintenance infusion for 24-48 hours. Periprocedural TEs and hemorrhagic events (HEs) were recorded. RESULTS A total of 331 patients were included, including 229 (69.2%) who received tirofiban administration (tirofiban group) and 102 (30.8%) who received only DAT (non-tirofiban group). Periprocedural TEs occurred in 12 (3.6%) patients, including eight (7.8%) in the non-tirofiban group and four (1.7%) in the tirofiban group. In multivariate analysis, patients receiving tirofiban administration had significantly lower TEs as compared with those who received only DAT (P=0.004). Balloon angioplasty and longer procedure time (>137 min) were also risk factors for TEs. Also, no increase was observed in the rate of HEs related to tirofiban administration. CONCLUSIONS The current study suggested that prophylactic administration of tirofiban combined with conventional oral DAT seems safe and efficient for preventing TEs during FD treatment of unruptured intracranial aneurysms. Balloon angioplasty and prolonged procedure are associated with a high risk of TEs.
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Affiliation(s)
- Qiaowei Wu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan Provincial People's Hospital and Henan University People's Hospital, Zhengzhou, China
| | - Qiuji Shao
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan Provincial People's Hospital and Henan University People's Hospital, Zhengzhou, China
| | - Li Li
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan Provincial People's Hospital and Henan University People's Hospital, Zhengzhou, China
| | - Xiaodong Liang
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan Provincial People's Hospital and Henan University People's Hospital, Zhengzhou, China
| | - Kaitao Chang
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan Provincial People's Hospital and Henan University People's Hospital, Zhengzhou, China
| | - Tianxiao Li
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan Provincial People's Hospital and Henan University People's Hospital, Zhengzhou, China
| | - Yingkun He
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan Provincial People's Hospital and Henan University People's Hospital, Zhengzhou, China
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17
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Affiliation(s)
- Samuel D Robinson
- Institute for Molecular Bioscience, The University of Queensland, St. Lucia, QLD, Australia.
| | - Irina Vetter
- Institute for Molecular Bioscience, The University of Queensland, St. Lucia, QLD, Australia; School of Pharmacy, Pharmacy Australia Centre of Excellence, The University of Queensland, Woolloongabba, QLD, Australia.
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18
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Deng Q, Zhang S, Li M, Zhang G, Feng W. Effects of two different glycoprotein platelet IIb/IIIa inhibitors and the clinical endpoints in patients with intracranial Pipeline flow diverter implant. J Interv Med 2020; 3:174-179. [PMID: 34805930 PMCID: PMC8562166 DOI: 10.1016/j.jimed.2020.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 07/11/2020] [Accepted: 08/03/2020] [Indexed: 11/15/2022] Open
Abstract
Objective To compare the antiplatelet effect and major adverse cerebrovascular events of Pipeline for intracranial aneurysms using glycoprotein IIb/IIIa antagonists (GPI) eptifibatide and tirofiban. Methods Retrospective analysis of relevant data of patients using GPIs combined with oral antiplatelet therapy in Nanfang Hospital of Southern Medical University from December 2017 to December 2019. The study was approved by the ethics Committee of Nanfang Hospital of Southern Medical University. According to the random use of GPIs drugs, they were assigned to the eptifibatide group and tirofiban group. Basic data, platelet inhibition rates at baseline, 24h and 72h after administration, short-term major adverse cerebrovascular events, and bleeding complications were compared between the two groups. Results A total of 47 patients were included in this study, including 24 patients in eptifibatide group and 23 patients in tirofiban group. There was no significant difference in average age (53.75 vs. 53.91 years) and body mass index (BMI) (24.39 vs. 22.73 kg/m2) between eptifibatide group and tirofiban group. There was no significant difference in coagulation factor function (R), fibrinogen function (K), fibrinolysis function (EPL), comprehensive coagulation index (Cl), arachidonic acid pathway inhibition rate (AA%) and adenosine diphosphate inhibition rate (ADP%). However, the baseline level of residual platelet function MA (ADP) in eptifibatide group was significantly higher than that in tirofiban group (50.79 vs. 35.29 mm, P = 0.0026). There was a statistical difference in the platelet aggregation function MA (65.38 vs. 62.54 mm, p = 0.0442), the rate of spontaneous hemorrhagic stroke (4.3% vs. 0%) and the rate of asymptomatic minor bleeding (26.08% vs. 4.1%) in the two groups (P < 0.05). Conclusion Both eptifibatide and tirofiban can effectively inhibit platelets, but the effect of etifeptide is better than that of tirofiban in preventing intracranial microhemorrhage and asymptomatic cerebral infarction.
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Affiliation(s)
| | | | | | | | - Wenfeng Feng
- Corresponding author. Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
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19
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Gargiulo G, Esposito G, Cirillo P, Nagler M, Minuz P, Campo G, Gragnano F, Manavifar N, Piccolo R, Avvedimento M, Tebaldi M, Wahl A, Hunziker L, Billinger M, Heg D, Windecker S, Valgimigli M. Facilitation Through Aggrastat or Cangrelor Bolus and Infusion Over PrasugreL: a MUlticenter Randomized Open-label Trial in PatientS with ST-elevation Myocardial InFarction Referred for PrimAry PercutaneouS InTERvention (FABOLUS FASTER) Trial: Design and Rationale : The FABOLUS FASTER Trial. J Cardiovasc Transl Res 2020; 14:110-119. [PMID: 32096064 DOI: 10.1007/s12265-020-09969-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/10/2020] [Indexed: 01/09/2023]
Abstract
Antithrombotic therapy is a critical component of the management of ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI). Rapid and profound inhibition of platelet reactivity has been shown to mitigate the ischemic risks and improve myocardial salvage. High residual platelet reactivity (HRPR) has been reported up to 4 or 6 h after loading dose of prasugrel or ticagrelor; therefore, multiple alternative strategies, including crushed or chewed oral tables or intravenous agents, have been investigated to provide a more rapid and sustained inhibition of platelet function and bridge the initial treatment gap. The FABOLUS FASTER is the first investigator-initiated, multicentre, open-label, prospective, randomized study to directly compare the pharmacodynamics effects of cangrelor, tirofiban, chewed or integer prasugrel. This study will add new insights in the management of antiplatelet therapy in patients with STEMI undergoing primary PCI and might be hypothesis-generating for future clinical trials in this field. The trial is registered on clinicaltrials.gov NCT02978040, and EudraCT 2017-001065-24.
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Affiliation(s)
- Giuseppe Gargiulo
- Department of Cardiology, Bern University Hospital, CH-3010, Bern, Switzerland
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Michael Nagler
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pietro Minuz
- Department of Medicine, Unit of General Medicine for the Study and Treatment of Hypertensive Disease, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, FE, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, RA, Italy
| | - Felice Gragnano
- Department of Cardiology, Bern University Hospital, CH-3010, Bern, Switzerland
| | - Negar Manavifar
- Department of Cardiology, Bern University Hospital, CH-3010, Bern, Switzerland
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Matteo Tebaldi
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, FE, Italy
| | - Andreas Wahl
- Department of Cardiology, Bern University Hospital, CH-3010, Bern, Switzerland
| | - Lukas Hunziker
- Department of Cardiology, Bern University Hospital, CH-3010, Bern, Switzerland
| | - Michael Billinger
- Department of Cardiology, Bern University Hospital, CH-3010, Bern, Switzerland
| | - Dik Heg
- Clinical Trials Unit (CTU) Bern, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, CH-3010, Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, CH-3010, Bern, Switzerland.
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Association of Hyperhomocysteinemia with Increased Coronary Microcirculatory Resistance and Poor Short-Term Prognosis of Patients with Acute Myocardial Infarction after Elective Percutaneous Coronary Intervention. BIOMED RESEARCH INTERNATIONAL 2020; 2020:1710452. [PMID: 31998781 PMCID: PMC6970506 DOI: 10.1155/2020/1710452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 12/09/2019] [Indexed: 11/24/2022]
Abstract
Background This study aims to investigate the coronary microcirculatory resistance and prognosis of patients with acute myocardial infarction (AMI) concomitant with hyperhomocysteinemia (HHcy) after an elective percutaneous coronary intervention (PCI). Methods A total of 101 patients that underwent elective PCI between May 2015 and July 2018 due to AMI were consecutively enrolled in this study. Patients were divided into a HHcy group (53) and a normal Hcy group (control; 48) based on their plasma homocysteine concentration. The characteristics of coronary angiography, the index of microcirculatory resistance (IMR) of infarct-related vessels (IRV), changes in left ventricular end diastolic diameter (LVEDd) and left ventricular ejection fraction (LVEF) before and after PCI, and the incidence of major adverse cardiovascular events (MACE) three months after PCI were compared between these groups. Results Compared to the results from the Hcy group, the HHcy group had a higher IMR. The HHcy group had significantly higher LVEDd and a lower LVEF than the Hcy group 3 months after PCI. Additionally, the incidence of MACE at three months after PCI was higher in the HHcy group than in the Hcy group. Pearson correlation analysis revealed a positive correlation with IMR in the HHcy group. Furthermore, there was a difference in the LVEDd measured at one day after PCI and at three months after PCI in the HHcy group. Conclusion AMI patients concomitant with HHcy that undergo elective PCI are prone to coronary microcirculatory dysfunction and have a poor cardiac function and poor prognosis at three months after PCI.
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Comparison of Routine Versus Selective Glycoprotein IIb/IIIa Inhibitors Usage in Primary Percutaneous Coronary Intervention (from the British Cardiovascular Interventional Society). Am J Cardiol 2019; 124:373-380. [PMID: 31146891 DOI: 10.1016/j.amjcard.2019.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 11/21/2022]
Abstract
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.
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Xiang Q, Pang X, Liu Z, Yang G, Tao W, Pei Q, Cui Y. Progress in the development of antiplatelet agents: Focus on the targeted molecular pathway from bench to clinic. Pharmacol Ther 2019; 203:107393. [PMID: 31356909 DOI: 10.1016/j.pharmthera.2019.107393] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 07/10/2019] [Indexed: 12/22/2022]
Abstract
Antiplatelet drugs serve as a first-line antithrombotic therapy for the management of acute ischemic events and the prevention of secondary complications in vascular diseases. Numerous antiplatelet therapies have been developed; however, currently available agents are still associated with inadequate efficacy, risk of bleeding, and variability in individual response. Understanding the mechanisms of platelet involvement in thrombosis and the clinical development process of antiplatelet agents is critical for the discovery of novel agents. The functions of platelets in thrombosis are regulated by two major mechanisms: the interaction between surface receptors and their ligands, and the downstream intracellular signaling pathways. Recently, most of the progress made in antiplatelet drug development has been achieved with P2Y receptor antagonists. Additionally, the usage of GP IIb/IIIa receptor antagonists has decreased, because it is associated with a higher risk of bleeding and thrombocytopenia. Agents targeting other platelet surface receptors such as PARs, TP receptor, EP3 receptor, GPIb-IX-V receptor, P-selectin, as well as intracellular signaling factors, such as PI3Kβ, have been evaluated in an attempt to develop the next generation of antiplatelet drugs, reduce or eliminate interpatient variability of drug efficacy and significantly lower the risk of drug-induced bleeding. The aim of this review is to describe the pathways of platelet activation in thrombosis, and summarize the development process of antiplatelet agents, as well as the preclinical and clinical evaluations performed on these agents.
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Affiliation(s)
- Qian Xiang
- Department of Pharmacy, Peking University First Hospital, No. 6, Da Hong Luo Chang Street, Xicheng District, Beijing 100034, China
| | - Xiaocong Pang
- Department of Pharmacy, Peking University First Hospital, No. 6, Da Hong Luo Chang Street, Xicheng District, Beijing 100034, China
| | - Zhenming Liu
- State Key Laboratory of Natural and Biomimetic Drugs, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Guoping Yang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Research Center of Drug Clinical Evaluation of Central South University, 138 TongZiPo Road, Changsha, Hunan 410013, China
| | - Weikang Tao
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Research Center of Drug Clinical Evaluation of Central South University, 138 TongZiPo Road, Changsha, Hunan 410013, China
| | - Qi Pei
- Shanghai Hengrui Pharmaceuticals Co., 279 Wenjing Road, Shanghai, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, No. 6, Da Hong Luo Chang Street, Xicheng District, Beijing 100034, China.
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Karathanos A, Lin Y, Dannenberg L, Parco C, Schulze V, Brockmeyer M, Jung C, Heinen Y, Perings S, Zeymer U, Kelm M, Polzin A, Wolff G. Routine Glycoprotein IIb/IIIa Inhibitor Therapy in ST-Segment Elevation Myocardial Infarction: A Meta-analysis. Can J Cardiol 2019; 35:1576-1588. [PMID: 31542257 DOI: 10.1016/j.cjca.2019.05.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/01/2019] [Accepted: 05/01/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Guidelines recommend adjunct glycoprotein IIb/IIIa inhibitors (GPIs) only in selected patients with acute ST-segment elevation myocardial infarction (STEMI). This study aimed to evaluate routine GPI use in STEMI treated with primary percutaneous coronary intervention. METHODS Online databases were searched for randomized controlled trials of routine GPI vs control therapy in STEMI. Data from retrieved studies were abstracted and evaluated in a comprehensive meta-analysis. Twenty-one randomized controlled trials with 8585 patients were included: 10 trials randomized tirofiban, 9 abciximab, 1 trial eptifibatide, and 1 trial used abciximab+tirofiban; only 1 trial used dual antiplatelet therapy with prasugrel/ticagrelor. RESULTS Routine GPI use was associated with a significant reduction in all-cause mortality at 30 days (2.4% [GPI] vs 3.2%; risk ratio [RR], 0.72; P = 0.01) and 6 months (3.7% vs 4.8%; RR, 0.76; P = 0.02), and a reduction in recurrent myocardial infarction (1.1% vs 2.1%; RR, 0.55; P = 0.0006), repeat revascularization (2.5% vs 4.1%; RR, 0.63; P = 0.0001), thrombolysis in myocardial infarction flow <3 after percutaneous coronary intervention (5.4% vs 8.2%; RR, 0.61; P < 0.0001), and ischemic stroke (RR, 0.42; P = 0.04). Major (4.7% vs 3.4%; RR, 1.35; P = 0.005) and minor bleedings (7.2% vs 5.1%; RR, 1.39; P = 0.006) but not intracranial bleedings (0.1% vs 0%; RR, 2.7; P = 0.37) were significantly increased under routine GPI. CONCLUSIONS Routine GPI administration in STEMI resulted in a reduction in mortality, driven by reductions in recurrent ischemic events-however predominantly in pre-prasugrel/ticagrelor trials. Trials with contemporary STEMI management are needed to confirm these findings.
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Affiliation(s)
| | - Yingfeng Lin
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Lisa Dannenberg
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Claudio Parco
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Volker Schulze
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | | | - Christian Jung
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Yvonne Heinen
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Stefan Perings
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Uwe Zeymer
- Heart Center Ludwigshafen, Clinic for Cardiology, Pulmonology, Vascular and Intensive Care Medicine, Ludwigshafen, Germany
| | - Malte Kelm
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany; CARID-Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | - Amin Polzin
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Georg Wolff
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
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Yoon CH, Lee HW, Kim YS, Lee SW, Yeom JA, Roh J, Baik SK. Preliminary Study of Tirofiban Infusion in Coil Embolization of Ruptured Intracranial Aneurysms. Neurosurgery 2018; 82:76-84. [PMID: 28419294 DOI: 10.1093/neuros/nyx177] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 03/15/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There have been some reports on the use of intra-arterial tirofiban in ruptured intracranial aneurysms, but few studies have reported on the use of 24 h of intravenous tirofiban infusion in patients with subarachnoid hemorrhage. OBJECTIVE To present our experience with intravenous tirofiban infusion, in the form of a monotherapy as well as in addition to intra-arterial tirofiban, as a prophylactic, and as a rescue management for thrombus in patients who have undergone embolization with coils for ruptured intracranial aneurysms. METHODS Between December 2008 and January 2015, we retrospectively reviewed 249 ruptured intracranial aneurysms that were treated with coiling at our institutions. A total of 28 patients harboring 28 ruptured and 3 unruptured intracranial aneurysms underwent intravenous tirofiban infusion during or after coil embolization of an aneurysm. Intra-arterial infusion of tirofiban via a microcatheter was also performed in 26 patients. RESULTS Thromboembolic formation during the procedure was detected in 25 cases. Intra-arterial tirofiban dissolved the thromboembolus under angiographic control after 10 or more minutes in 19 (76%) of 25 patients. Two intracranial hemorrhagic complications (increase in the extent of hematoma) occurred during the follow-up period. Two cases of other complications occurred: hematuria and perioral bleeding. CONCLUSION Intravenous tirofiban, as a monotherapy or in addition to intra-arterial tirofiban for thrombotic complications, seems to be useful as a treatment for acute aneurysm. However, alternatives to tirofiban should be considered if an associated hematoma is discovered before a patient receives a tirofiban infusion.
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Affiliation(s)
- Chang Hyo Yoon
- Department of Neurology, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ho-Won Lee
- Department of Neurology, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Young Soo Kim
- Department of Neurosur-gery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Sang Won Lee
- Department of Neurosur-gery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Jeong A Yeom
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Jieun Roh
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Seung Kug Baik
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
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Kuang J, Li L, Ma X, Gan J, Jiang S. Efficacy and Safety of Bivalirudin Plus Half/Full Dose of Tirofiban in Patients Undergoing Emergency Percutaneous Coronary Intervention. INT J PHARMACOL 2018. [DOI: 10.3923/ijp.2018.506.512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Robinson SD, Undheim EAB, Ueberheide B, King GF. Venom peptides as therapeutics: advances, challenges and the future of venom-peptide discovery. Expert Rev Proteomics 2017; 14:931-939. [DOI: 10.1080/14789450.2017.1377613] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Samuel D. Robinson
- Institute for Molecular Bioscience, University of Queensland, St Lucia, Australia
- Centre for Advanced Imaging, University of Queensland, St Lucia, Australia
| | | | | | - Glenn F. King
- Institute for Molecular Bioscience, University of Queensland, St Lucia, Australia
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Fabris E, Kilic S, Schellings DAAM, ten Berg JM, Kennedy MW, van Houwelingen KG, Giannitsis E, Kolkman E, Ottervanger JP, Hamm C, van’t Hof AWJ. Long-term mortality and prehospital tirofiban treatment in patients with ST elevation myocardial infarction. Heart 2017; 103:1515-1520. [DOI: 10.1136/heartjnl-2017-311181] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 05/09/2017] [Accepted: 05/10/2017] [Indexed: 01/28/2023] Open
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Wilmer CI. Intracoronary high-dose bolus tirofiban administration during complex coronary interventions: A United States-based case series. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 19:112-116. [PMID: 28684062 DOI: 10.1016/j.carrev.2017.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 05/31/2017] [Accepted: 06/16/2017] [Indexed: 10/19/2022]
Abstract
The GP IIb/IIIa inhibitors (GPIs) rapidly provide therapeutic levels of platelet aggregation inhibition and serve as adjunct pharmacotherapy to oral P2Y12 inhibitors that exhibit a significant delay in onset of action for patients with Acute Coronary Syndrome (ACS). Intracoronary (IC) administration of the high dose bolus (HDB) tirofiban has not been extensively studied. Compared to intravenous delivery, IC administration can lead to higher local drug concentration and, therefore, provide instantaneous disruption of platelet aggregation in the culprit vessel. This report describes the successful resolution of thrombus using IC HDB tirofiban in 7 high-risk coronary interventions with complications such as recurrent thrombosis and cardiogenic shock in ACS patients. This report represents the first case series of IC HDB tirofiban performed in North America and suggests that IC HDB tirofiban may represent an effective and safe strategy to achieve rapid thrombus resolution in ACS patients.
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Affiliation(s)
- Charles I Wilmer
- Piedmont Heart Institute, 275 Collier Road NW Suite 500, Atlanta, GA 30309, USA.
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29
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Reducing system delays in treatment of ST elevation myocardial infarction and confronting the challenges of late presentation in low and middle-income countries. Indian Heart J 2017; 69 Suppl 1:S1-S5. [PMID: 28400032 PMCID: PMC5388017 DOI: 10.1016/j.ihj.2016.12.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Kupó P, Aradi D, Tornyos A, Tőkés-Füzesi M, Komócsi A. Assessment of platelet function in patients receiving tirofiban early after primary coronary intervention. Interv Med Appl Sci 2016; 8:135-140. [PMID: 28180001 PMCID: PMC5283770 DOI: 10.1556/1646.8.2016.4.8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Background Following percutaneous coronary intervention, combined antiplatelet therapy is necessary. Platelet function testing (PFT) has prognostic value and may be applied in the risk assessment of acute coronary syndrome. In case of combined antiplatelet therapy, PFT may require special laboratory methods, as different antiplatelet agents may influence test results. Materials and methods Platelet functions were measured in stent thrombosis-segment elevation myocardial infarction patients receiving aspirin, clopidogrel, and tirofiban. The first sampling was obtained immediately after the termination of administration of tirofiban. The second sample was drawn at a randomly assigned time between 1 and 6 h. The third sampling was done after a minimum of 24 h of tirofiban cessation. Adenosine diphosphate (ADP)- and thrombin receptor-activating peptide (TRAP)-induced aggregations were measured. Results Thirty-seven patients were included. Both TRAP- and ADP-induced aggregation values were significantly lower immediately after tirofiban termination, than after 24 h [TRAP: 26.41 ± 25.00 units (U) vs. 109.86 ± 23.69 U, p < 0.0001; ADP: 17.43 ± 10.10 U vs. 43.92 ± 23.35 U, p ≤ 0.0001]. Elimination half-life of tirofiban and clopidogrel were 1.34 ± 0.49 and 1.269 ± 0.78, respectively. Conclusion ADP-induced residual platelet reactivity is significantly influenced by the presence of concurrent glycoprotein IIb/IIIa inhibitor. In patients receiving combined antiplatelet treatment, ADP-receptor-specific efficiency measurements are valid only after total elimination of GPIIb/IIIa inhibitors.
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Affiliation(s)
- Péter Kupó
- Heart Institute, University of Pécs , Pécs, Hungary
| | - Dániel Aradi
- Department of Cardiology, Heart Center Balatonfüred , Balatonfüred, Hungary , and Heart and Vascular Center, Semmelweis University , Budapest, Hungary
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31
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Protective Effects of Tirofiban on Myocardial Ischemia–Reperfusion Injury in Rabbits. Am J Ther 2016; 23:e1427-e1435. [DOI: 10.1097/mjt.0000000000000280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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32
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Comparison of heparin, bivalirudin, and different glycoprotein IIb/IIIa inhibitor regimens for anticoagulation during percutaneous coronary intervention: A network meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2016; 17:535-545. [PMID: 27842901 DOI: 10.1016/j.carrev.2016.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 09/26/2016] [Indexed: 11/21/2022]
Abstract
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.
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Savonitto S, De Luca G, Goldstein P, van T' Hof A, Zeymer U, Morici N, Thiele H, Montalescot G, Bolognese L. Antithrombotic therapy before, during and after emergency angioplasty for ST elevation myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:173-190. [PMID: 26124456 DOI: 10.1177/2048872615590148] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The first three hours after symptom onset hold the maximum potential for myocardial reperfusion and salvage in ST-elevation myocardial infarction (STEMI) patients. During this period timely primary percutaneous coronary intervention (PPCI) or, when PPCI is not promptly feasible, pre-hospital administration of fibrinolyis or a glycoprotein IIb/IIIa-inhibitor (GPI) have been shown to restore coronary patency and reperfusion and even result in myocardial infarction (MI) abortion. On the other hand, oral antiplatelet therapy may not yet guarantee sufficient platelet inhibition. Patients presenting after this golden time have less, if any, benefit from an aggressive antithrombotic treatment prior to PPCI. Antithrombotic treatment during primary angioplasty should be tailored on the basis of the coronary thrombotic burden, vascular approach and the patient's risk of bleeding complications. A GPI-based approach may be favourable in patients presenting early with large MI and high thrombus burden, whereas a bivalirudin-based approach without GPI may be preferred in patients with higher bleeding risk. There are no data to support the use of GPI in bailout conditions. The powerful oral P2Y12 inhibitors, prasugrel and ticagrelor, have been clearly shown to prevent stent thrombosis and recurrent ischaemic events after emergency percutaneous coronary intervention in STEMI patients. Open issues remaining are the treatment of patients with high bleeding risk, such as the elderly and those requiring anticoagulation, as well as the duration of dual antiplatelet therapy after STEMI.
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Affiliation(s)
| | | | | | | | - Uwe Zeymer
- 5 Klinikum Ludwigshafen, Ludwigshafen, Germany
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Adamo M, Ariotti S, Costa F, Curello S, Moschovitis A, de Vries T, White HD, Windecker S, Valgimigli M. Phosphate- or Citrate-Buffered Tirofiban Versus Unfractionated Heparin and its Impact on Thrombocytopenia and Clinical Outcomes in Patients With Acute Coronary Syndrome. JACC Cardiovasc Interv 2016; 9:1667-76. [DOI: 10.1016/j.jcin.2016.05.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 05/09/2016] [Accepted: 05/18/2016] [Indexed: 01/09/2023]
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35
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Lee WC, Chen HC, Fang HY, Hsueh SK, Chen CJ, Yang CH, Yip HK, Wu CJ, Fang CY, Hang CL. Comparison of different strategies for acute ST-segment elevation myocardial infarction with high thrombus burden in clinical practice: Symptom-free outcome at one year. Heart Lung 2016; 44:487-93. [PMID: 26572772 DOI: 10.1016/j.hrtlng.2015.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 08/14/2015] [Accepted: 08/15/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the clinical effects of different strategies for preventing coronary microvascular obstruction in ST elevation myocardial infarction (STEMI) patients with a high thrombus-burden plaque. METHODS Between January, 2007 and December, 2012, 354 patients suffering from STEMI with high thrombus-burden were enrolled and divided into three groups as the first group received a GP IIb/IIIa inhibitor, and the second group received a distal protective device, and the third group was treated with primary PCI alone. RESULTS A high percentage of patients in the GP IIb/IIIa inhibitor (96.8% and 90.5%), distal protective device (99.3% and 87.6%) had better thirty-day and one-year symptom-free outcomes when compared with PCI only group (91.6% and 65.6%) (P = 0.008 and P < 0.001; respectively). CONCLUSIONS Treatment with intracoronary GP IIb/IIIa inhibitor injection or distal protection device to prevent coronary microvascular obstruction was demonstrated to increase the occurrences of thirty-day and one-year symptom-free outcomes; thus, these treatments can help decrease post-MI medical care costs.
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Affiliation(s)
- Wei-Chieh Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Huang-Chung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Shu-Kai Hsueh
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Chien-Jen Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Cheng-Hsu Yang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Chiung-Jen Wu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC.
| | - Chih-Yuan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Chi-Ling Hang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
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Glycoprotein IIb/IIIa inhibitors: The resurgence of tirofiban. Vascul Pharmacol 2016; 78:10-6. [DOI: 10.1016/j.vph.2015.07.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 07/12/2015] [Accepted: 07/13/2015] [Indexed: 11/18/2022]
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Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2015; 37:267-315. [PMID: 26320110 DOI: 10.1093/eurheartj/ehv320] [Citation(s) in RCA: 4245] [Impact Index Per Article: 471.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Zhao XM, Gao CY, Chu YJ, Yang L, Yang XZ, Xu WK, He WQ, Zhang PR, Liu XY, Tian LX. Fondaparinux vs. enoxaparin in patients with non-ST elevation acute coronary syndromes (NSTE-ACS) treated with percutaneous coronary intervention and tirofiban: an exploratory study in China. J Clin Pharm Ther 2015; 40:584-589. [PMID: 26249542 DOI: 10.1111/jcpt.12315] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 07/02/2015] [Indexed: 11/28/2022]
Affiliation(s)
- X. M. Zhao
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - C. Y. Gao
- Department of Cardiology; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - Y. J. Chu
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - L. Yang
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - X. Z. Yang
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - W. K. Xu
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - W. Q. He
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - P. R. Zhang
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - X. Y. Liu
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
| | - L. X. Tian
- Department of Emergency; Henan Provincial People's Hospital and the People's Hospital of Zhengzhou University; Zhengzhou China
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Austin D, Mackay DF, Morley R, Christie J, Hennigan B, de Belder MA, Pell JP, Oldroyd KG. High-bolus dose tirofiban compared with abciximab in primary percutaneous coronary intervention: a propensity score-matched outcome study. EUROINTERVENTION 2015; 10:1187-94. [DOI: 10.4244/eijy14m05_11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Mathew A, Abraham BJ, Fischer L, Punnoose E. Popliteal artery thrombosis following total knee arthroplasty managed successfully with percutaneous intervention. BMJ Case Rep 2014; 2014:bcr-2014-206936. [PMID: 25414222 DOI: 10.1136/bcr-2014-206936] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute popliteal artery thrombosis is a rare complication following total knee arthroplasty (TKA), with sequelae including critical limb ischaemia and amputation. We report the case of a 54-year-old woman who developed acute popliteal artery thrombosis following TKA, presenting 2 weeks after the initial symptoms. While such cases have been traditionally managed with surgical thrombectomy or bypass grafting, percutaneous aspiration thrombectomy is an emerging alternative management strategy in the early postoperative period. However, in patients in whom intervention is delayed, the efficacy of percutaneous aspiration thrombectomy is not known. Our patient had complete resolution of thrombus following percutaneous thrombus aspiration, angioplasty and tirofiban administration. Prompt diagnosis and early percutaneous intervention may avert critical limb ischaemia in patients presenting with popliteal artery thrombosis following TKA.
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Affiliation(s)
- Anoop Mathew
- Department of Cardiology, Kolenchery Heart Institute, MOSC Medical College Hospital, Kolenchery, Kerala, India
| | - Biju Jacob Abraham
- Joint Replacement and Arthroscopy Unit, MOSC Medical College Hospital, Kolenchery, Kerala, India
| | - Louie Fischer
- Department of Cardiology, Kolenchery Heart Institute, MOSC Medical College Hospital, Kolenchery, Kerala, India
| | - Eapen Punnoose
- Department of Cardiology, Kolenchery Heart Institute, MOSC Medical College Hospital, Kolenchery, Kerala, India
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 64:e139-e228. [PMID: 25260718 DOI: 10.1016/j.jacc.2014.09.017] [Citation(s) in RCA: 2076] [Impact Index Per Article: 207.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:e344-426. [PMID: 25249585 DOI: 10.1161/cir.0000000000000134] [Citation(s) in RCA: 636] [Impact Index Per Article: 63.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
BACKGROUND Antiplatelet therapy is a cornerstone in coronary artery disease management. However, patients with acute coronary syndrome still remain at risk of recurrent cardiovascular events despite the advance of medical therapy. OBJECTIVE This article provides a review of antiplatelet agents used in cardiovascular diseases and focus on updates in the past 5 years. METHOD Peer-reviewed clinical trials and relevant treatment guidelines were identified from MEDLINE and Current Content database (from 1966 to April 15, 2013) using search terms aspirin, clopidogrel, prasugrel, ticagrelor, glycoprotein IIb/IIIa inhibitors, antiplatelet agents, coronary artery disease, acute coronary syndrome, pharmacology, pharmacokinetics, and pharmacodynamics. Citations from the available articles were also reviewed for additional references. RESULTS In unstable angina and non-ST-segment elevation myocardial infarction (MI), dual antiplatelet therapy (aspirin and clopidogrel) demonstrated a reduction in death from cardiovascular causes, nonfatal MI, or stroke (relative risk 0.80; 95% confidence interval [CI], 0.72-0.90). In ST-segment elevation MI, dual antiplatelet therapy reduced the rate of occluded infarct-related artery/death or recurrent MI (95% CI, 24%-47%). Newer agents such as prasugrel, when compared to clopidogrel, reduced death from vascular causes, MI, or stroke in patients undergoing percutaneous coronary intervention (PCI; hazard ratio [HR], 0.81; 95% CI 0.73-0.90) but not in those receiving medical management only. When compared to clopidogrel, ticagrelor reduces death from vascular causes, MI, or stroke (HR: 0.84; 95% CI, 0.77-0.92) in patients undergoing PCI or receiving medical management only. Both the agents, however, increase the risk of bleeding in certain patient population. CONCLUSIONS In the last 5 years, newer antiplatelet agents, including prasugrel and ticagrelor, have been demonstrated to reduce recurrent cardiovascular events compared to standard therapy and, however, also caused increase bleeding in selected patient populations. Newer agents including shorter acting P2Y12 inhibitor or antiplatelets that target other receptors are being evaluated to improve/maintain therapeutic efficacy yet minimize the risk of bleeding.
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Glycoprotein IIb/IIIa inhibitors use and outcome after percutaneous coronary intervention for non-ST elevation myocardial infarction. BIOMED RESEARCH INTERNATIONAL 2014; 2014:643981. [PMID: 24895595 PMCID: PMC4034401 DOI: 10.1155/2014/643981] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 04/17/2014] [Indexed: 12/16/2022]
Abstract
AIMS We investigate the effect of glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors on long-term outcomes following percutaneous coronary intervention (PCI) after non-ST elevation myocardial infarction (NSTEMI). Meta-analyses indicate that these agents are associated with improved short-term outcomes. However, many trials were undertaken before the routine use of P2Y12 inhibitors. Recent studies yield conflicting results and registry data have suggested that GP IIb/IIIa inhibitors may cause more bleeding than what trials indicate. METHODS AND RESULTS This retrospective observational study involves 3047 patients receiving dual-antiplatelet therapy who underwent PCI for NSTEMI. Primary outcome was all-cause mortality. Major adverse cardiac events (MACE) were a secondary outcome. Mean follow-up was 4.6 years. Patients treated with GP IIb/IIIa inhibitors were younger with fewer comorbidities. Although the unadjusted Kaplan-Meier analysis suggested that GP IIb/IIIa inhibitor use was associated with improved outcomes, multivariate analysis (including propensity scoring) showed no benefit for either survival (P = 0.136) or MACE (P = 0.614). GP IIb/IIIa inhibitor use was associated with an increased risk of major bleeding (P = 0.021). CONCLUSION Although GP IIb/IIIa inhibitor use appeared to improve outcomes after PCI for NSTEMI, patients who received GP IIb/IIIa inhibitors tended to be at lower risk. After multivariate adjustment we observed no improvement in MACE or survival and an increased risk of major bleeding.
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Giordano A, D'Angelillo A, Romano S, D'Arrigo P, Corcione N, Bisogni R, Messina S, Polimeno M, Pepino P, Ferraro P, Romano MF. Tirofiban induces VEGF production and stimulates migration and proliferation of endothelial cells. Vascul Pharmacol 2014; 61:63-71. [PMID: 24751361 DOI: 10.1016/j.vph.2014.04.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 03/24/2014] [Accepted: 04/02/2014] [Indexed: 11/17/2022]
Abstract
Tirofiban is a fibrinogen receptor antagonist, generated using the tripeptide Arg-Gly-Asp (RGD) as a template. RGD activates integrin receptors and integrin-mediated signals are necessary for normal cells to promote survival and stimulate cell cycle progression. We investigated whether tirofiban activated growth-stimulatory signals in endothelium. For this study human umbilical vein endothelial cells (HUVEC) and human aortic endothelial cells (HAEC) were used. Analysis of cell proliferation, by cell counts, showed that the number of endothelial cells doubled after 72 h of culture in the absence of tirofiban, while they were tripled and even quadrupled, in the presence of increasing doses of the drug. Moreover, tirofiban-stimulated cells had a greater ability to migrate through the transwell filters of Boyden chamber, compared to unstimulated cells. The scratch assay, which mimics cell migration during wound healing, showed that tirofiban stimulated HUVECs to migrate into the leading hedge of the scratch. Western blot showed that tirofiban increased the expression levels of VEGF and the downstream effectors Erk and cyclin D. An inhibitor of VEGFR2 counteracted tirofiban-induced-proliferation, suggesting a role for VEGF in such effect. Our study shows that tirofiban stimulates the migration and proliferation of endothelial cells suggesting that it can promote endothelial repair. Ex vivo cultures of arterial rings confirmed the growth stimulatory effect of tirofiban on endothelium. Thus, the benefits of tirofiban in those with acute coronary syndromes undergoing PTCA may be due to rapid endothelization of damaged vessel, besides antiplatelet effects.
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Affiliation(s)
- Arturo Giordano
- Invasive Cardiology Unit, Pineta Grande Hospital, Castelvolturno, Italy
| | - Anna D'Angelillo
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | - Simona Romano
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | - Paolo D'Arrigo
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | - Nicola Corcione
- Invasive Cardiology Unit, Pineta Grande Hospital, Castelvolturno, Italy
| | - Rita Bisogni
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | - Stefano Messina
- Invasive Cardiology Unit, Pineta Grande Hospital, Castelvolturno, Italy
| | - Michele Polimeno
- Invasive Cardiology Unit, Pineta Grande Hospital, Castelvolturno, Italy
| | - Paolo Pepino
- Cardiovascular Surgery, Pineta Grande Hospital, Castelvolturno, Italy
| | - Paolo Ferraro
- Invasive Cardiology Unit, Pineta Grande Hospital, Castelvolturno, Italy
| | - Maria Fiammetta Romano
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy.
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Topcu S, Karal H, Kaya A, Bakirci EM, Tanboga IH, Kurt M, Aksakal E, Acikel M, Sevimli S. The Safety and Efficacy of 12 Versus 24 Hours of Tirofiban Infusion in Patients Undergoing Primary Percutaneous Coronary Intervention. Clin Appl Thromb Hemost 2014; 21:783-9. [DOI: 10.1177/1076029614529841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Aim: We aimed to investigate the 6-month efficacy and safety of postprocedural 12-hour tirofiban administration versus 24-hour tirofiban administration in patients with ST-segment elevated myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI). Methods: This retrospective study enrolled 349 patients with STEMI who underwent primary PCI. Following the administration of bolus tirofiban after primary PCI, those receiving a 12-hour tirofiban infusion as the maintenance dose were classified as group 1 (n = 123) while those receiving a 24-hour infusion were classified as group 2 (n = 226). In-hospital and 6-month major adverse cardiac events were recorded. Results: There were no statistically significant differences between the 2 groups regarding in-hospital efficacy (in-hospital death: 4.4% vs 5.7%, P = .600 and stent thrombosis 1.8% vs 1.6%, P = .921) and in-hospital safety (2.6% vs 1.6% for major bleeding and 5.3% vs 4.1% for minor bleeding, P = .562). During the 6-month follow-up period, the incidence of the recurrent revascularization (16.1% vs 15.5%, odds ratio [OR] = 1.05 [0.47-3.67]), the repeated nonfatal acute coronary syndrome and/or stent thrombosis (27% vs 24.4%, P = .598, OR = 1.02 [0.42-2.48]), and the cardiovascular deaths (6.6% vs 6.5%, P = .943, OR = 1.03 [0.43-2.43]) were comparable between group 1 and group 2. Conclusion: Our study revealed that 12-hour tirofiban administration versus 24-hour tirofiban administration in STEMI who underwent primary PCI was similar with respect to in-hospital efficacy and safety and major adverse cardiac events during 6-month follow-up.
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Affiliation(s)
- Selim Topcu
- Department of Cardiology, Medical School, Ataturk University, Erzurum, Turkey
| | - Huseyin Karal
- Department of Cardiology, Medical School, Ataturk University, Erzurum, Turkey
| | - Ahmet Kaya
- Department of Cardiology, Erzurum Education and Research Hospital, Erzurum, Turkey
| | - Eftal Murat Bakirci
- Department of Cardiology, Medical School, Ataturk University, Erzurum, Turkey
| | | | - Mustafa Kurt
- Department of Cardiology, Erzurum Education and Research Hospital, Erzurum, Turkey
| | - Enbiya Aksakal
- Department of Cardiology, Medical School, Ataturk University, Erzurum, Turkey
| | - Mahmut Acikel
- Department of Cardiology, Medical School, Ataturk University, Erzurum, Turkey
| | - Serdar Sevimli
- Department of Cardiology, Medical School, Ataturk University, Erzurum, Turkey
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Li W, Fu X, Xue H, Wang Y, Wang X, Zhao Y, Geng W, Yang Z, Gu X, Hao G, Jiang Y, Fan W, Wu W, Li S. Efficacy and safety of standard-dose versus half-dose tirofiban in patients with non-ST elevation acute coronary syndromes undergoing early percutaneous coronary intervention. Cardiovasc Ther 2014; 31:210-4. [PMID: 22954393 DOI: 10.1111/1755-5922.12004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION To explore the optimal dosage of tirofiban associated with double benefits of efficacy and safety in patients with non-ST elevation acute coronary syndromes (NSTE-ACS) undergoing early percutaneous coronary intervention (PCI). AIMS A total of 163 patients were included in this study (78 in SD group versus 85 in HD group). In SD (HD) group, tirofiban was administered intravenously with a bolus dose of 10 (5) μg/kg within 3 min and followed by continuous intravenous infusion of 0.15 (0.075) μg/kg/min for 48 h. Within 24 h on admission, patients underwent CAG or CAG+PCI. The angiographic results (initial TIMI, final TIMI/CTFC/TMPG) were evaluated. Platelet aggregation rate (PAR) was measured before and 2, 24, 48 h after bolus tirofiban. MACEs were evaluated at 7-day, 30-day, and 6-month follow-up. Bleeding was observed at 7 days. RESULTS The proportions of TIMI grade 3 seemed higher in SD group before and after PCI followed by a better myocardial perfusion, but not statistically different (P = 0.26/0.08). PAR was lower in SD group than that in HD group at 2 h after bolus tirofiban (P = 0.03). MACEs were not statistically different at 7, 30 day, and 6 month in two groups. The incidence of minor bleeding was significantly lower in HD group than that in SD group (8.2% vs. 20.5%, P = 0.04). The risk of bleeding would increase under the conditions of decreased PAR, increased dose of tirofiban and decreased CCr. CONCLUSION Half-dose tirofiban was not inferior to standard-dose in efficacy, what is more, half-dose tirofiban showed a better safety characteristic of lower bleeding risk. Therefore, half-dose tirofiban is recommended to patients with NSTE-ACS undergoing early PCI.
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Affiliation(s)
- Wei Li
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Jia Z, Guo M, Zhang YQ, Liang HQ, Song Y. Short-term effect of upstream administration in comparison to deferred injection of tirofiban on patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. J Interv Cardiol 2013; 26:332-9. [PMID: 23844823 DOI: 10.1111/joic.12044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND High bolus dose tirofiban has been demonstrated to provide greater inhibition of platelet aggregation, but the most appropriate timing of its administration remains unknown. OBJECTIVES To evaluate the efficacy of upstream vs. deferred administration of tirofiban in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI) on clinical outcomes. METHODS The 660 patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention were divided into upstream (n=330, administration of tirofiban to all patients in emergency room) and deferred groups (n=330, treatment of patients with large thrombus burden or no-reflow phenomenon in cardiac catheterization laboratory during PCI). The primary end-points were death, nonfatal myocardial infarction (MI), stent thrombosis (ST), revascularization of targeted vessels (TVR) or major adverse cardiac events (MACE) at 1 month and 6 months following PCI, with safety end-point at 7 days. RESULTS Compared with that of the deferred group, there was a significant increase of left ventricular ejection fraction (LVEF) in the upstream group within 7 days (55.5 ± 6.6% vs. 54.6 ± 7.9%, P=0.011). The rates of 7-day and 1-month MACE in the upstream group were lower than those in the deferred group (1.5% vs. 4.2%, 3.3% vs. 7.0%, P=0.037 and 0.034, respectively). However, there were higher tendencies for major and minor bleedings in the upstream group (1.8% vs. 0.9%, 2.7% vs. 1.5%, P=0.315 and 0.280, respectively). CONCLUSION To the Chinese patients with acute myocardial infarction undergoing primary PCI, upstream administration of tirofiban was slightly superior to deferred injection for short-term clinical outcomes.
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Affiliation(s)
- Zhi Jia
- TEDA International Cardiovascular Hospital, Cardiovascular Clinical College of Tianjin Medical University, TEDA, Tianjin, China
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Muñiz-Lozano A, Rollini F, Franchi F, Angiolillo DJ. Update on platelet glycoprotein IIb/IIIa inhibitors: recommendations for clinical practice. Ther Adv Cardiovasc Dis 2013; 7:197-213. [PMID: 23818658 DOI: 10.1177/1753944713487781] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Antiplatelet therapy is the cornerstone of treatment for patients with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention (PCI). Glycoprotein IIb/IIIa receptors mediate platelet aggregation, representing the final common pathway of platelet-mediated thrombosis. Therefore, agents blocking this pathway may be desirable for the treatment of patients with ACS and PCI. Glycoprotein IIb/IIIa receptor inhibitors have been widely investigated and have been key to the pharmacological advancements in the field. However, although GPIs have been important to reduce ischemic complications, their elevated risk of bleeding complications remains a major limitation. The poor prognostic implications, including increased mortality, associated with bleeding complication underscores the need for alternative treatment options. Over the past years there have been several advancements in antithrombotic pharmacology which have led to changes in recommendations for GPI usage in clinical practice. This is an overview of the most recent clinical trial data on GPIs, and provides practical insight on their modern day use in ACS therapy.
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Affiliation(s)
- Ana Muñiz-Lozano
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA. dominick.angiolillo@jax. ufl.edu
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Valgimigli M, Campo G, Gambetti S, Bolognese L, Ribichini F, Colangelo S, de Cesare N, Rodriguez AE, Russo F, Moreno R, Piva T, Sheiban I, Penzo C, Prati F, Nazzaro MS, Díaz Fernández JF, Vassanelli C, Parrinello G, Ferrari R. Three-year follow-up of the MULTIcentre evaluation of Single high-dose Bolus TiRofiban versus Abciximab with Sirolimus-eluting STEnt or Bare-Metal Stent in Acute Myocardial Infarction StudY (MULTISTRATEGY). Int J Cardiol 2013; 165:134-41. [DOI: 10.1016/j.ijcard.2011.07.106] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 07/29/2011] [Accepted: 07/31/2011] [Indexed: 11/26/2022]
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