1
|
Sullivan AE, Nanna MG, Wang TY, Bhatt DL, Angiolillo DJ, Mehran R, Banerjee S, Cantrell S, Jones WS, Rymer JA, Washam JB, Rao SV, Ohman EM. Bridging Antiplatelet Therapy After Percutaneous Coronary Intervention: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:1550-1563. [PMID: 34620413 DOI: 10.1016/j.jacc.2021.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 11/26/2022]
Abstract
Patients undergoing early surgery after coronary stent implantation are at increased risk for mortality from ischemic and hemorrhagic complications. The optimal antiplatelet strategy in patients who cannot discontinue dual antiplatelet therapy (DAPT) before surgery is unclear. Current guidelines, based on surgical and clinical characteristics, provide risk stratification for bridging therapy with intravenous antiplatelet agents, but management is guided primarily by expert opinion. This review summarizes perioperative risk factors to consider before discontinuing DAPT and reviews the data for intravenous bridging therapies. Published reports have included bridging options such as small molecule glycoprotein IIb/IIIa inhibitors (eptifibatide or tirofiban) and cangrelor, an intravenous P2Y12 inhibitor. However, optimal management of these complex patients remains unclear in the absence of randomized controlled data, without which an argument can be made both for and against the use of perioperative intravenous bridging therapy after discontinuing oral P2Y12 inhibitors. Multidisciplinary risk assessment remains a critical component of perioperative care.
Collapse
Affiliation(s)
- Alexander E Sullivan
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA. https://twitter.com/aesullivan37
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Tracy Y Wang
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Deepak L Bhatt
- Division of Cardiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Roxana Mehran
- Division of Cardiology, Mount Sinai Hospital, New York, New York, USA
| | - Subhash Banerjee
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sarah Cantrell
- Duke University Medical Center Library & Archives, Duke University School of Medicine, Durham, North Carolina, USA
| | - W Schuyler Jones
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jennifer A Rymer
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Sunil V Rao
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - E Magnus Ohman
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA.
| |
Collapse
|
2
|
Abstract
Integrins are heterodimeric cell surface receptors ensuring the mechanical connection between cells and the extracellular matrix. In addition to the anchorage of cells to the extracellular matrix, these receptors have critical functions in intracellular signaling, but are also taking center stage in many physiological and pathological conditions. In this review, we provide some historical, structural, and physiological notes so that the diverse functions of these receptors can be appreciated and put into the context of the emerging field of mechanobiology. We propose that the exciting journey of the exploration of these receptors will continue for at least another new generation of researchers.
Collapse
Affiliation(s)
- Michael Bachmann
- Department of Cell Physiology and Metabolism, University of Geneva, Centre Médical Universitaire , Geneva , Switzerland ; and Faculty of Medicine and Health Technology, Tampere University, and Fimlab Laboratories , Tampere , Finland
| | - Sampo Kukkurainen
- Department of Cell Physiology and Metabolism, University of Geneva, Centre Médical Universitaire , Geneva , Switzerland ; and Faculty of Medicine and Health Technology, Tampere University, and Fimlab Laboratories , Tampere , Finland
| | - Vesa P Hytönen
- Department of Cell Physiology and Metabolism, University of Geneva, Centre Médical Universitaire , Geneva , Switzerland ; and Faculty of Medicine and Health Technology, Tampere University, and Fimlab Laboratories , Tampere , Finland
| | - Bernhard Wehrle-Haller
- Department of Cell Physiology and Metabolism, University of Geneva, Centre Médical Universitaire , Geneva , Switzerland ; and Faculty of Medicine and Health Technology, Tampere University, and Fimlab Laboratories , Tampere , Finland
| |
Collapse
|
3
|
Affiliation(s)
- Dermot Cox
- Molecular & Cellular Therapeutics Royal College of Surgeons in Ireland Dublin Ireland
| |
Collapse
|
4
|
Lazarovici P, Marcinkiewicz C, Lelkes PI. From Snake Venom's Disintegrins and C-Type Lectins to Anti-Platelet Drugs. Toxins (Basel) 2019; 11:toxins11050303. [PMID: 31137917 PMCID: PMC6563238 DOI: 10.3390/toxins11050303] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 05/16/2019] [Accepted: 05/24/2019] [Indexed: 12/13/2022] Open
Abstract
Snake venoms are attractive natural sources for drug discovery and development, with a number of substances either in clinical use or in research and development. These drugs were developed based on RGD-containing snake venom disintegrins, which efficiently antagonize fibrinogen activation of αIIbβ3 integrin (glycoprotein GP IIb/IIIa). Typical examples of anti-platelet drugs found in clinics are Integrilin (Eptifibatide), a heptapeptide derived from Barbourin, a protein found in the venom of the American Southeastern pygmy rattlesnake and Aggrastat (Tirofiban), a small molecule based on the structure of Echistatin, and a protein found in the venom of the saw-scaled viper. Using a similar drug discovery approach, linear and cyclic peptides containing the sequence K(R)TS derived from VP12, a C-type lectin protein found in the venom of Israeli viper venom, were used as a template to synthesize Vipegitide, a novel peptidomimetic antagonist of α2β1 integrin, with anti-platelet activity. This review focus on drug discovery of these anti-platelet agents, their indications for clinical use in acute coronary syndromes and percutaneous coronary intervention based on several clinical trials, as well as their adverse effects.
Collapse
Affiliation(s)
- Philip Lazarovici
- School of Pharmacy Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 91120, Israel.
| | - Cezary Marcinkiewicz
- Department of Bioengineering, College of Engineering, Temple University, Philadelphia, PA 19122, USA.
| | - Peter I Lelkes
- Department of Bioengineering, College of Engineering, Temple University, Philadelphia, PA 19122, USA.
| |
Collapse
|
5
|
Van Tuyl JS, Newsome AS, Hollis IB. Perioperative Bridging With Glycoprotein IIb/IIIa Inhibitors Versus Cangrelor: Balancing Efficacy and Safety. Ann Pharmacother 2019; 53:726-737. [PMID: 30646761 DOI: 10.1177/1060028018824640] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To review the efficacy and safety of perioperative administration of intravenous (IV) antiplatelet agents as a substitute for oral P2Y12 inhibitors and to provide clinicians guidance on optimal and cost-effective use of these medications. DATA SOURCES A MEDLINE literature search (1950 to November 2018) was performed using the key search terms abciximab, bridging, cangrelor, cardiac surgery, coronary artery bypass surgery, eptifibatide, intravenous antiplatelet agent, and tirofiban. Additional references were identified from a review of literature citations. STUDY SELECTION AND DATA EXTRACTION In all, 18 original research reports and case reports/series were included in the review. DATA SYNTHESIS Prevention of postoperative bleeding is critical to decrease morbidity and mortality after cardiac surgery. IV antiplatelet medications have short half-lives and are frequently used to substitute for oral P2Y12 inhibitors to allow platelet function recovery before procedures. Functional recovery of platelets is delayed after abciximab discontinuation and increases postoperative bleeding risk. Eptifibatide and tirofiban have similar pharmacokinetic/pharmacodynamic properties and comparable efficacy and safety in the setting of perioperative bridging. Cangrelor may be considered in patients with renal insufficiency as decreased clearance of eptifibatide or tirofiban may increase the risk of postoperative bleeding. Relevance to Patient Care and Clinical Practice: Comparative studies of IV antiplatelet medications have not been published. Appropriate use of IV antiplatelet medications can prevent perioperative ischemic events and bleeding. CONCLUSIONS Eptifibatide, tirofiban, and cangrelor are preferred over abciximab as a perioperative bridge. The choice of agent should be tailored to clinical characteristics of the patient and institutional acquisition costs.
Collapse
Affiliation(s)
- Joseph S Van Tuyl
- 1 SSM Health St Louis University Hospital, MO, USA.,2 St Louis College of Pharmacy, MO, USA
| | - Andrea Sikora Newsome
- 3 The University of Georgia College of Pharmacy, Augusta, GA, USA.,4 Augusta University Medical Center, Augusta, GA, USA
| | - Ian B Hollis
- 5 University of North Carolina Medical Center, Chapel Hill, NC, USA.,6 UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| |
Collapse
|
6
|
A Review of Antiplatelet Activity of Traditional Medicinal Herbs on Integrative Medicine Studies. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 2019:7125162. [PMID: 30719065 PMCID: PMC6335729 DOI: 10.1155/2019/7125162] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 11/27/2018] [Indexed: 12/13/2022]
Abstract
Thrombotic events mainly occurred by platelet activation and aggregation. The vascular occlusion causes serious disease states such as unstable angina, ischemic stroke, and heart attack. Due to the pervading of thrombotic diseases, new antiplatelet drugs are necessary for preventing and treating arterial thrombosis without adverse side effects. Traditional medicinal herbs have been used for the treatment of human ailments for a long time. The clinically useful and safe products from traditional medicinal herbs were identified and developed in numerous pharmacological approaches. A complementary system of traditional medicinal herbs is a good candidate for pharmacotherapy. However, it still has a limitation in its function and efficacy. Thus, it is necessary to study the mode of action of traditional medicinal herbs as alternative therapeutic agents. In this review, we focused on our current understanding of the regulatory mechanisms of traditional medicinal herbs in antiplatelet activity and antithrombotic effect of traditional medicinal herbs on platelet function.
Collapse
|
7
|
David V, Succar BB, de Moraes JA, Saldanha-Gama RFG, Barja-Fidalgo C, Zingali RB. Recombinant and Chimeric Disintegrins in Preclinical Research. Toxins (Basel) 2018; 10:E321. [PMID: 30087285 PMCID: PMC6116119 DOI: 10.3390/toxins10080321] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 07/23/2018] [Accepted: 07/27/2018] [Indexed: 01/31/2023] Open
Abstract
Disintegrins are a family of small cysteine-rich peptides, found in a wide variety of snake venoms of different phylogenetic origin. These peptides selectively bind to integrins, which are heterodimeric adhesion receptors that play a fundamental role in the regulation of many physiological and pathological processes, such as hemostasis and tumor metastasis. Most disintegrins interact with integrins through the RGD (Arg-Gly-Asp) sequence loop, resulting in an active site that modulates the integrin activity. Some variations in the tripeptide sequence and the variability in its neighborhood result in a different specificity or affinity toward integrin receptors from platelets, tumor cells or neutrophils. Recombinant forms of these proteins are obtained mainly through Escherichia coli, which is the most common host used for heterologous expression. Advances in the study of the structure-activity relationship and importance of some regions of the molecule, especially the hairpin loop and the C-terminus, rely on approaches such as site-directed mutagenesis and the design and expression of chimeric peptides. This review provides highlights of the biological relevance and contribution of recombinant disintegrins to the understanding of their binding specificity, biological activities and therapeutic potential. The biological and pharmacological relevance on the newest discoveries about this family of integrin-binding proteins are discussed.
Collapse
Affiliation(s)
- Victor David
- Laboratório de Hemostase e Venenos, Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21.941-902, Brazil.
| | - Barbara Barbosa Succar
- Laboratório de Hemostase e Venenos, Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21.941-902, Brazil.
| | - João Alfredo de Moraes
- Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21.941-902, Brazil.
| | - Roberta Ferreira Gomes Saldanha-Gama
- Laboratório de Farmacologia Celular e Molecular, Departamento de Biologia Celular, IBRAG, Universidade do Estado do Rio de Janeiro, Rio de Janeiro 20.551-030, Brazil.
| | - Christina Barja-Fidalgo
- Laboratório de Farmacologia Celular e Molecular, Departamento de Biologia Celular, IBRAG, Universidade do Estado do Rio de Janeiro, Rio de Janeiro 20.551-030, Brazil.
| | - Russolina Benedeta Zingali
- Laboratório de Hemostase e Venenos, Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21.941-902, Brazil.
| |
Collapse
|
8
|
Razzuk MA, Pierce TB, Razzuk AM. Platelets and Hemostasis: The Role of Glycoprotein IIb/IIIa in Platelet Aggregation. Proc (Bayl Univ Med Cent) 2018. [DOI: 10.1080/08998280.1997.11930019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Maruf A. Razzuk
- Department of Thoracic and Cardiovascular Surgery, Baylor University Medical Center
| | - Tada B. Pierce
- Department of Thoracic and Cardiovascular Surgery, Baylor University Medical Center
| | | |
Collapse
|
9
|
Pang Z, Zhao W, Yao Z. Cardioprotective Effects of Nicorandil on Coronary Heart Disease Patients Undergoing Elective Percutaneous Coronary Intervention. Med Sci Monit 2017; 23:2924-2930. [PMID: 28617765 PMCID: PMC5484606 DOI: 10.12659/msm.902324] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Nicorandil is a nicotinamide ester commonly prescribed for treatment of patients with coronary heart disease (CHD). In the present study, we aimed to explore the cardioprotective effects of nicorandil on CHD patients undergoing elective percutaneous coronary intervention (PCI). Material/Methods One hundred patients with CHD undergoing PCI were randomly divided into a control group (n=48) and a nicorandil group (n=52). Patients in the control group received traditional therapy, and while patients in the nicorandil group received nicorandil before PCI in addition to the traditional therapy. After PCI, all patients underwent coronary angiogram, and TIMI frame count (TFC) was calculated. Plasma levels of cardiac troponin I (cTnI), creatine kinase-MB (CK-MB), myeloperoxidase (MPO), and malondialdehyde (MDA) were determined before and at 6, 18, and 24 h after PCI. Moreover, systolic blood pressure (SBP), mean blood pressure (DBP), heart rate (HR), and left ventricular ejection fractions (LVEF) were recorded before and 3 months after PCI. Results There was a significant difference in the rate of no-reflow (P=0.036) between the 2 groups. The blood frames and levels of cTnI, CK-MB, MPO, and MDA in the nicorandil group were significantly decreased compared to the control group (all P<0.05). Moreover, administration of nicorandil markedly decreased SBP, MBP, and HR, but obviously increased LVEF at 3 months after PCI (P<0.05 or P<0.01). Conclusions Nicorandil exerts cardioprotective effects on CHD patients undergoing elective PCI by decreasing PCI-related myocardial injury and rate of no-reflow and improvement of LVEF.
Collapse
Affiliation(s)
- Zhihua Pang
- Department of Cardiology, Tianjin Union Medical Center, Tianjin, China (mainland)
| | - Wei Zhao
- Heyuan Community Health Service Centers of Hongqiao District, Tianjin, China (mainland)
| | - Zhuhua Yao
- Department of Cardiology, Tianjin Union Medical Center, Tianjin, China (mainland)
| |
Collapse
|
10
|
Abstract
Aspirin has become a widely accepted platelet function inhibitor and is used to prevent arterial occlusions in coronary cerebral and peripheral vascular disease. The results of clinical studies with aspirin in the area of peripheral arterial occlusive disease are critically reviewed. Two thienopyridine compounds, ticlopidine and clopidogrel, have been effectively used in the prevention of myocardial infarction and stroke in several clinical trials, especially in the recently published CAPRIE-trial. Potent new platelet function inhibitors recently were developed. Intravenous treatment with abciximab, a new platelet membrane glycoprotein IIb/IIIa-inhibitor, effectively prevented coronary reocclusions in patients with high-risk coronary events. A series of promising new oral IIb/IIIa- inhibitors have been developed and may become effective drugs in the prevention of reocclusions in patients with periph eral vascular disease and in coronary or cerebral vascular dis ease. Key Words: Antiplatelet agents—Aspirin—Peripheral arterial disease—Ticlopidine—Clopidogrel—GPIIb/IIIa inhibitor.
Collapse
Affiliation(s)
- Hans Klaus Breddin
- International Institute of Thrombosis and Vascular Diseases, Frankfurt, Germany
| |
Collapse
|
11
|
Abstract
Platelets play an important, but often under-recognized role in cardiovascular disease. For example, the normal response of the platelet can be altered, either by increased pro-aggregatory stimuli or by diminished anti-aggregatory substances to produce conditions of increased platelet activation/aggregation and occur in active cardiovascular disease states both on a chronic (e.g. stable angina pectoris) and acute basis (e.g. acute myocardial infarction). In addition, platelet hyperaggregability is also associated with the risk factors for coronary artery disease (e.g. smoking, hypertension, and hypercholesterolaemia). Finally, the utility of an increasing range of anti-platelet therapies in the management of the above disease states further emphasizes the pivotal role platelets play in the pathogenesis of cardiovascular disease. This paper provides a comprehensive overview of the normal physiologic role of platelets in maintain homeostasis, the pathophysiologic processes that contribute to platelet dysfunction in cardiovascular disease and the associated role and benefits of anti-platelet therapies.
Collapse
Affiliation(s)
- Scott Willoughby
- Cardiology Unit, The Queen Elizabeth Hospital, Adelaide University, Adelaide, South Australia, Australia
| | - Andrew Holmes
- Cardiology Unit, The Queen Elizabeth Hospital, Adelaide University, Adelaide, South Australia, Australia
| | - Joseph Loscalzo
- The Whitaker Cardiovascular Institute and Evans Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Flores JJ, Zhang Y, Klebe DW, Lekic T, Fu W, Zhang JH. Small molecule inhibitors in the treatment of cerebral ischemia. Expert Opin Pharmacother 2014; 15:659-80. [PMID: 24491068 DOI: 10.1517/14656566.2014.884560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Stroke is the world's second leading cause of death. Although recombinant tissue plasminogen activator is an effective treatment for cerebral ischemia, its limitations and ischemic stroke's complex pathophysiology dictate an increased need for the development of new therapeutic interventions. Small molecule inhibitors (SMIs) have the potential to be used as novel therapeutic modalities for stroke, since many preclinical and clinical trials have established their neuroprotective capabilities. AREAS COVERED This paper provides a summary of the pathophysiology of stroke as well as clinical and preclinical evaluations of SMIs as therapeutic interventions for cerebral ischemia. Cerebral ischemia is broken down into four mechanisms in this article: thrombosis, ischemic insult, mitochondrial injury and immune response. Insight is provided into preclinical and current clinical assessments of SMIs targeting each mechanism as well as a summary of reported results. EXPERT OPINION Many studies demonstrated that pre- or post-treatment with certain SMIs significantly ameliorated adverse effects from stroke. Although some of these promising SMIs moved on to clinical trials, they generally failed, possibly due to the poor translation of preclinical to clinical experiments. Yet, there are many steps being taken to improve the quality of experimental research and translation to clinical trials.
Collapse
Affiliation(s)
- Jerry J Flores
- Loma Linda University School of Medicine, Department of Physiology and Pharmacology , Risley Hall, Room 223, Loma Linda, CA 92354 , USA
| | | | | | | | | | | |
Collapse
|
14
|
Schneider DJ, Aggarwal A. Development of glycoprotein IIb–IIIa antagonists: translation of pharmacodynamic effects into clinical benefit. Expert Rev Cardiovasc Ther 2014; 2:903-13. [PMID: 15500435 DOI: 10.1586/14779072.2.6.903] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This article will review the development of glycoprotein IIb-IIIa antagonists, with particular emphasis on the characteristics and pharmacodynamic studies of each agent that is available for clinical use. Abciximab is a Fab fragment of the 7E3 antibody that has high affinity and a slow rate of dissociation from glycoprotein IIb-IIIa. In contrast, the small molecules eptifibatide and tirofiban, have a much more rapid rate of dissociation, with an off time of 10 to 15 s. Accordingly, the circulating pool of abciximab is predominantly associated with platelets, whereas maintenance of a consistent concentration of tirofiban and eptifibatide in the blood is critical in order to achieve and sustain their inhibitory effects. The affinity of abciximab and tirofiban for glycoprotein IIb-IIIa are substantially greater than that of eptifibatide, necessitating maintenance of greater molar concentrations of eptifibatide in blood in order to achieve effective inhibition of the binding of fibrinogen to the activated conformer of glycoprotein IIb-IIIa.
Collapse
Affiliation(s)
- David J Schneider
- University of Vermont, 208 South Park Drive, Suite 2, Colchester, VT 05446, USA.
| | | |
Collapse
|
15
|
Bosch X, Marrugat J, Sanchis J. Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial medical treatment of non-ST segment elevation acute coronary syndromes. Cochrane Database Syst Rev 2013:CD002130. [PMID: 24203004 DOI: 10.1002/14651858.cd002130.pub4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND During percutaneous coronary intervention (PCI), and in non-ST segment elevation acute coronary syndromes (NSTEACS), the risk of acute vessel occlusion by thrombosis is high. Glycoprotein IIb/IIIa blockers strongly inhibit platelet aggregation and may prevent mortality and myocardial infarction. This is an update of a Cochrane review first published in 2001, and previously updated in 2007 and 2010. OBJECTIVES To assess the efficacy and safety effects of glycoprotein IIb/IIIa blockers when administered during PCI, and as initial medical treatment in patients with NSTEACS. SEARCH METHODS We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 12, 2012), MEDLINE (OVID, 1946 to January Week 1 2013) and EMBASE (OVID, 1947 to Week 1 2013) on 11 January 2013. SELECTION CRITERIA Randomised controlled trials comparing intravenous IIb/IIIa blockers with placebo or usual care. DATA COLLECTION AND ANALYSIS Two authors independently selected studies for inclusion, assessed trial quality and extracted data. We collected major bleeding as adverse effect information from the trials. We used odds ratios (OR) and 95% confidence intervals (CI) for effect measures. MAIN RESULTS Sixty trials involving 66,689 patients were included. During PCI (48 trials with 33,513 participants) glycoprotein IIb/IIIa blockers decreased all-cause mortality at 30 days (OR 0.79, 95% CI 0.64 to 0.97) but not at six months (OR 0.90, 95% CI 0.77 to 1.05). All-cause death or myocardial infarction was decreased both at 30 days (OR 0.66, 95% CI 0.60 to 0.72) and at six months (OR 0.75, 95% CI 0.64 to 0.86), although severe bleeding was increased (OR 1.39, 95% CI 1.21 to 1.61; absolute risk increase (ARI) 8.0 per 1000). The efficacy results were homogeneous for every endpoint according to the clinical condition of the patients, but were less marked for patients pre-treated with clopidogrel, especially in patients without acute coronary syndromes.As initial medical treatment of NSTEACS (12 trials with 33,176 participants), IIb/IIIa blockers did not decrease mortality at 30 days (OR 0.90, 95% CI 0.79 to 1.02) or at six months (OR 1.00, 95% CI 0.87 to 1.15), but slightly decreased death or myocardial infarction at 30 days (OR 0.91, 95% CI 0.85 to 0.98) and at six months (OR 0.88, 95% CI 0.81 to 0.96), although severe bleeding was increased (OR 1.29, 95% CI 1.14 to 1.45; ARI 1.4 per 1000). AUTHORS' CONCLUSIONS When administered during PCI, intravenous glycoprotein IIb/IIIa blockers reduce the risk of all-cause death at 30 days but not at six months, and reduce the risk of death or myocardial infarction at 30 days and at six months, at a price of an increase in the risk of severe bleeding. The efficacy effects are homogeneous but are less marked in patients pre-treated with clopidogrel where they seem to be effective only in patients with acute coronary syndromes. When administered as initial medical treatment in patients with NSTEACS, these agents do not reduce mortality although they slightly reduce the risk of death or myocardial infarction.
Collapse
Affiliation(s)
- Xavier Bosch
- Department of Cardiology, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Villarroel 170, Barcelona, Spain, 08036
| | | | | |
Collapse
|
16
|
Bosch X, Marrugat J, Sanchis J. Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial medical treatment of non-ST segment elevation acute coronary syndromes. Cochrane Database Syst Rev 2013:CD002130. [PMID: 24136036 DOI: 10.1002/14651858.cd002130.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND During percutaneous coronary intervention (PCI), and in non-ST segment elevation acute coronary syndromes (NSTEACS), the risk of acute vessel occlusion by thrombosis is high. Glycoprotein IIb/IIIa blockers strongly inhibit platelet aggregation and may prevent mortality and myocardial infarction. This is an update of a Cochrane review first published in 2001, and previously updated in 2007 and 2010. OBJECTIVES To assess the efficacy and safety effects of glycoprotein IIb/IIIa blockers when administered during PCI, and as initial medical treatment in patients with NSTEACS. SEARCH METHODS We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 12, 2012), MEDLINE (OVID, 1946 to January Week 1 2013) and EMBASE (OVID, 1947 to Week 1 2013) on 11 January 2013. SELECTION CRITERIA Randomised controlled trials comparing intravenous IIb/IIIa blockers with placebo or usual care. DATA COLLECTION AND ANALYSIS Two authors independently selected studies for inclusion, assessed trial quality and extracted data. We collected major bleeding as adverse effect information from the trials. We used odds ratios (OR) and 95% confidence intervals (CI) for effect measures. MAIN RESULTS Sixty trials involving 66,689 patients were included. During PCI (48 trials with 33,513 participants) glycoprotein IIb/IIIa blockers decreased all-cause mortality at 30 days (OR 0.79, 95% CI 0.64 to 0.97) but not at six months (OR 0.90, 95% CI 0.77 to 1.05). All-cause death or myocardial infarction was decreased both at 30 days (OR 0.66, 95% CI 0.60 to 0.72) and at six months (OR 0.75, 95% CI 0.64 to 0.86), although severe bleeding was increased (OR 1.39, 95% CI 1.21 to 1.61; absolute risk increase (ARI) 8.0 per 1000). The efficacy results were homogeneous for every endpoint according to the clinical condition of the patients, but were less marked for patients pre-treated with clopidogrel, especially in patients without acute coronary syndromes.As initial medical treatment of NSTEACS (12 trials with 33,176 participants), IIb/IIIa blockers did not decrease mortality at 30 days (OR 0.90, 95% CI 0.79 to 1.02) or at six months (OR 1.00, 95% CI 0.87 to 1.15), but slightly decreased death or myocardial infarction at 30 days (OR 0.91, 95% CI 0.85 to 0.98) and at six months (OR 0.88, 95% CI 0.81 to 0.96), although severe bleeding was increased (OR 1.29, 95% CI 1.14 to 1.45; ARI 1.4 per 1000). AUTHORS' CONCLUSIONS When administered during PCI, intravenous glycoprotein IIb/IIIa blockers reduce the risk of all-cause death at 30 days but not at six months, and reduce the risk of death or myocardial infarction at 30 days and at six months, at a price of an increase in the risk of severe bleeding. The efficacy effects are homogeneous but are less marked in patients pre-treated with clopidogrel where they seem to be effective only in patients with acute coronary syndromes. When administered as initial medical treatment in patients with NSTEACS, these agents do not reduce mortality although they slightly reduce the risk of death or myocardial infarction.
Collapse
Affiliation(s)
- Xavier Bosch
- Department of Cardiology, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Villarroel 170, Barcelona, Spain, 08036
| | | | | |
Collapse
|
17
|
Abstract
From the initial description of platelets in 1882, their propensity to aggregate and to contribute to thrombosis was apparent. Indeed, excessive platelet aggregation is associated with myocardial infarction and other thrombotic diseases whereas Glanzmann thrombasthenia, in which platelet aggregation is reduced, is a bleeding syndrome. Over the last half of the 20th century, many investigators have provided insights into the cellular and molecular basis for platelet aggregation. The major membrane protein on platelets, integrin αIIbβ3, mediates this response by rapidly transiting from its resting to an activated state in which it serves as a receptor for ligands that can bridge platelets together. Monoclonal antibodies, natural products, and small peptides were all shown to inhibit αIIbβ3 dependent platelet aggregation, and these inhibitors became the forerunners of antagonists that proceeded through preclinical testing and into large patient trials to treat acute coronary syndromes, particularly in the context of percutaneous coronary interventions. Three such αIIbβ3 antagonists, abciximab, eptifibatide, and tirofiban, received Food and Drug Administration approval. Over the past 15 years, millions of patients have been treated with these αIIbβ3 antagonists and many lives have been saved by their administration. With the side effect of increased bleeding and the development of new antithrombotic drugs, the use of αIIbβ3 antagonists is waning. Nevertheless, they are still widely used for the prevention of periprocedural thrombosis during percutaneous coronary interventions. This review focuses on the biology of αIIbβ3, the development of its antagonists, and some of the triumphs and shortcomings of αIIbβ3 antagonism.
Collapse
Affiliation(s)
- Kamila Bledzka
- Department of Molecular Cardiology, Joseph J. Jacobs Center for Thrombosis and Vascular Biology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | |
Collapse
|
18
|
Abstract
Disintegrins, a family of polypeptides released in the venoms of viperid snakes (vipers and rattlesnakes) by the proteolytic processing of multidomain metalloproteinases, selectively block the function of β(1) and β(3) integrin receptors. Few of the proteins isolated and characterized from snake venoms have proven to be more structural and functional versatile than the disintegrins. Not surprisingly, 25 years after their discovery, our knowledge on the evolutionary history and the molecular determinants modulating the integrin inhibitory activity of disintegrins still remain fragmentary. This paper highlights some seminal contributions, including personal accounts of pioneer authors, related to basic and applied research on disintegrins. Investigators have evaluated disintegrin applications in therapies for a number of pathologies in which integrin receptors play relevant roles, particularly myocardial infarction and inappropriate tumor angiogenesis. Completing the continuing story of the disintegrin family by applying novel research approaches may hold the key to learn how to use deadly toxins as therapeutic agents.
Collapse
Affiliation(s)
- Juan J Calvete
- Instituto de Biomedicina de Valencia, CSIC, Jaime Roig 11, 46010 Valencia, Spain.
| |
Collapse
|
19
|
Lang SH, Manning N, Armstrong N, Misso K, Allen A, Di Nisio M, Kleijnen J. Treatment with tirofiban for acute coronary syndrome (ACS): a systematic review and network analysis. Curr Med Res Opin 2012; 28:351-70. [PMID: 22292469 DOI: 10.1185/03007995.2012.657299] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the efficacy of tirofiban in comparison to usual care or other GPIIb/IIIa antagonists (eptifibatide and abciximab). Results were analysed by drug administration with planned percutaneous coronary intervention (PCI) or as medical management without planned PCI, and separately for STEMI or NSTE ACS patients. RESEARCH DESIGN AND METHODS A systematic review was performed of randomized controlled trials of tirofiban, abciximab, eptifibatide or usual care given to patients with acute coronary syndrome. Nine databases were searched up to March 2010. Pair-wise meta-analysis was used to combine all available direct comparisons; indirect comparisons and network analysis were performed when this was not possible. The primary outcome was MACE (major adverse cardiac event). RESULTS The search yielded 8, 119 records and 50 trials were included (total number of patients = 52,958). Compared to usual care, high and medium-dose tirofiban (25 and 10 µg/kg/min) administered with planned PCI reduced MACE at 30 days for patients with STEMI (RR 0.67, 95% CI 0.45, 0.99; RR 0.28, 95% CI 0.10, 0.80), but was not effective as a medical management. Medium-dose tirofiban (10 µg/kg/min) administered with planned PCI or low dose (0.4 µg/kg/min) as medical management reduced the risk of MACE for patients with NSTE ACS (RR 0.39, 95% CI 0.21, 0.75; RR 0.58, 95% CI 0.41, 0.83) in comparison to usual care, but at the expense of increased thrombocytopenia (RR 3.26, 95% CI 1.31, 8.13). Evidence from RCTs and network analysis indicated tirofiban and abciximab were equally effective and safe. Comparing tirofiban and eptifibatide treatment by indirect and network analysis produced inconclusive results. CONCLUSIONS Tirofiban was more effective than usual care for STEMI and NSTE ACS patients receiving planned PCI, and NSTE ACS patients receiving medical management. Tirofiban and abciximab were equally effective. Comparisons of tirofiban and eptifibatide were inconclusive.
Collapse
Affiliation(s)
- S H Lang
- Kleijnen Systematic Reviews, Unit 6, Escrick Business Park, Riccall Road, Escrick, York YO19 6FD, UK.
| | | | | | | | | | | | | |
Collapse
|
20
|
Abstract
Glycoprotein (GP) IIb-IIIa antagonists inhibit the aggregation of activated platelets. Three agents are approved for clinical use. In this review, the characteristics of each agent, their pharmacodynamic profile, results in pivotal clinical trials and the associated clinical implications are discussed. GP IIb-IIIa antagonists have greatest benefit when used as adjunctive therapy during percutaneous coronary intervention (PCI) when the patient has intra-coronary thrombosis. These agents appear to provide greatest benefit when used in combination with heparin. The clinical niche for parenteral GP IIb-IIIa antagonists is evolving. The rapid onset and offset of GP IIb-IIIa antagonists plus dosing designed to inhibit extensively platelet aggregation differentiates them from oral agents. The contemporary niche appears to include patients in transition, such as individuals requiring emergent PCI before oral agents are fully active and for unstable patients requiring transport to PCI centres, particularly in patients likely to have intracoronary thrombus. Subsequent studies should evaluate the optimal duration of therapy with GP IIb-IIIa antagonists.
Collapse
Affiliation(s)
- David J Schneider
- Cardiology Unit, Department of Medicine and Cardiovascular Research Unit, University of Vermont, Burlington, VT 05446, USA.
| |
Collapse
|
21
|
Saab F, Ionescu C, J. Schweiger M. Bleeding risk and safety profile related to the use of eptifibatide: a current review. Expert Opin Drug Saf 2012; 11:315-24. [DOI: 10.1517/14740338.2012.650164] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
22
|
Abstract
Mortality from ischemic cardiac disease in adults has been dramatically reduced by the development of novel therapies for inhibiting platelet function. Circulating platelets are maintained in a resting state and are activated at sites of vascular injury by exquisitely controlled mechanisms, thereby maintaining vascular integrity without causing intravascular thrombosis. As it became clear that platelets play a central role in arterial thrombosis, the processes of platelet activation, adhesion, and aggregation became logical targets for the development of antithrombotic agents.
Collapse
Affiliation(s)
- Karen M Hook
- The Carole and Ray Neag Comprehensive Cancer Center, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, USA.
| | | |
Collapse
|
23
|
Occlusive thrombi arise in mammals but not birds in response to arterial injury: evolutionary insight into human cardiovascular disease. Blood 2011; 118:3661-9. [PMID: 21816834 DOI: 10.1182/blood-2011-02-338244] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Mammalian platelets are small, anuclear circulating cells that form tightly adherent, shear-resistant thrombi to prevent blood loss after vessel injury. Platelet thrombi that form in coronary and carotid arteries also underlie common vascular diseases such as myocardial infarction and stroke and are the target of drugs used to treat these diseases. Birds have high-pressure cardiovascular systems like mammals but generate nucleated thrombocytes rather than platelets. Here, we show that avian thrombocytes respond to many of the same activating stimuli as mammalian platelets but are unable to form shear-resistant aggregates ex vivo. Avian thrombocytes are larger than mammalian platelets, spread less efficiently on collagen, and express much lower levels of the α(₂b)β₃ integrin required for aggregate formation, features predicted to make thrombocyte aggregates less resistant than platelets are to the high fluid shear forces of the arterial vasculature. In vivo carotid vessel injury stimulates the formation of occlusive platelet thrombi in mice but not in the size- and flow-matched carotid artery of the Australian budgerigar. These studies indicate that unique physical and molecular features of mammalian platelets enable them to form shear-resistant arterial thrombi, an essential element in the pathogenesis of human cardiovascular diseases.
Collapse
|
24
|
Abstract
Exogenous factors isolated from venoms of snakes and saliva of haematophagous animals that affect thrombosis and haemostasis have contributed significantly to the development of diagnostic agents, research tools and life-saving drugs. Here, I discuss recent advances in the discovery, structural and functional characterisation, and mechanism of action of new procoagulant and anti-haemostatic proteins. In nature, these factors have evolved to target crucial 'bottlenecks' in the coagulation cascade and platelet aggregation. Several simple protein scaffolds are used to target a wide variety of target proteins and receptors exhibiting functional divergence. Different protein scaffolds have also evolved to target identical, physiologically relevant key enzymes or receptors exhibiting functional convergence. At times, exogenous factors bind to the same target protein, but at distinct sites, to differentially attenuate their functions exhibiting mechanistic divergence within the same family of proteins. The structure-function relationships of these factors are subtle and complicated but represent an exciting challenge. These studies provide ample opportunities to design highly specific and precise ligands to achieve desired biological target function. Although only a small number of them have been characterised to date, the molecular and mechanical diversities of these exogenous factors and their contributions to understanding molecular and cellular events in thrombosis and haemostasis as well as developing diagnostic and research tools and therapeutic agents, is outstanding. Based on the current status, I have attempted to identify future potential and prospects in this area of research.
Collapse
Affiliation(s)
- R M Kini
- Protein Science Laboratory, Department of Biological Sciences, Faculty of Science, National University of Singapore, Singapore.
| |
Collapse
|
25
|
Hanna N, Fiorilli P, Gaglia MA, Torguson R, Vita A, Ben-Dor I, Xue Z, Waksman R, Bernardo NL. Low-Dose Protamine to Facilitate Earlier Sheath Removal from the Femoral Artery After Peripheral Endovascular Intervention. J Interv Cardiol 2011; 24:278-84. [PMID: 21535150 DOI: 10.1111/j.1540-8183.2011.00642.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Nicholas Hanna
- Division of Cardiology, Washington Hospital Center, Washington, DC, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Llau JV, Ferrandis R, Sierra P, Gómez-Luque A. Prevention of the renarrowing of coronary arteries using drug-eluting stents in the perioperative period: an update. Vasc Health Risk Manag 2010; 6:855-67. [PMID: 20957131 PMCID: PMC2952454 DOI: 10.2147/vhrm.s7402] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The management of patients scheduled for surgery with a coronary stent, and receiving 1 or more antiplatelet drugs, has many controversies. The premature discontinuation of antiplatelet drugs substantially increases the risk of stent thrombosis (ST), myocardial infarction, and cardiac death, and surgery under an altered platelet function could also lead to an increased risk of bleeding in the perioperative period. Because of the conflict in the recommendations, this article reviews the current antiplatelet protocols after positioning a coronary stent, the evidence of increased risk of ST associated with the withdrawal of antiplatelet drugs and increased bleeding risk associated with its maintenance, the different perioperative antiplatelet protocols when patients are scheduled for surgery or need an urgent operation, and the therapeutic options if excessive bleeding occurs.
Collapse
Affiliation(s)
- Juan V Llau
- Department of Anaesthesiology and Critical Care Medicine, Hospital Clínic Universitari, València, Spain.
| | | | | | | |
Collapse
|
27
|
Bosch X, Marrugat J, Sanchis J. Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial medical treatment of non-ST segment elevation acute coronary syndromes. Cochrane Database Syst Rev 2010:CD002130. [PMID: 20824831 DOI: 10.1002/14651858.cd002130.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND During percutaneous coronary intervention (PCI), and in non-ST segment elevation acute coronary syndromes (NSTEACS), the risk of acute vessel occlusion by thrombosis is high. IIb/IIIa blockers strongly inhibit platelet aggregation and may prevent mortality and myocardial infarction (MI). This is an update of a Cochrane review first published in 2001, and previously updated in 2007. OBJECTIVES To assess the effects and safety of IIb/IIIa blockers when administered during PCI, and as initial medical treatment in patients with NSTEACS. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 3, 2009), MEDLINE (1966 to October 2009), and EMBASE (1980 to October 2009). SELECTION CRITERIA Randomised controlled trials comparing intravenous IIb/IIIa blockers with placebo or usual care. DATA COLLECTION AND ANALYSIS Two authors independently selected studies for inclusion, assessed trial quality and extracted data. We collected major bleeding as adverse effect information from the trials. Odds ratios (OR) and 95% confidence intervals (CI) were used for effect measures. MAIN RESULTS Forty-eight trials involving 62,417 patients were included. During PCI, IIb/IIIa blockers decreased mortality at 30 days (OR 0.76, 95% CI 0.62 to 0.95) and at six months (OR 0.84, 95% CI 0.71 to 1.00). Death or MI was decreased both at 30 days (OR 0.65, 95% CI 0.60 to 0.72), and at 6 months (OR 0.70, 95% CI 0.61 to 0.81), although severe bleeding was increased (OR 1.38, 95% CI 1.20 to 1.59; absolute risk increase (ARI) 8.0 per 1000). The efficacy results were homogeneous for every endpoint according to the clinical condition of the patients, but were less marked for patients pre-treated with clopidogrel, especially in patients without ACS.As initial medical treatment of NSTEACS, IIb/IIIa blockers did not decrease mortality at 30 days (OR 0.91, 95% CI 0.80 to 1.03) or at six months (OR 1.00, 95% CI 0.87 to 1.15), but slightly decreased death or MI at 30 days (OR 0.92, 95% CI 0.86 to 0.99) and at six months (OR 0.88, 95% CI 0.81 to 0.96), although severe bleeding was increased (OR 1.27, 95% CI 1.12 to 1.43; ARI 1.4 per 1000). AUTHORS' CONCLUSIONS When administered during PCI, intravenous IIb/IIIa blockers reduce the risk of death and of death or MI at 30 days and at six months, at a price of an increase in the risk of severe bleeding. The efficacy effects are homogeneous but are less marked in patients pre-treated with clopidogrel where they seem to be effective only in patients with ACS. When administered as initial medical treatment in patients with NSTEACS, these agents do not reduce mortality although they slightly reduce the risk of death or MI.
Collapse
Affiliation(s)
- Xavier Bosch
- Department of Cardiology, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Villarroel 170, Barcelona, Spain, 08036
| | | | | |
Collapse
|
28
|
Shah I, Khan SO, Malhotra S, Fischell T. Eptifibatide: The evidence for its role in the management of acute coronary syndromes. CORE EVIDENCE 2010; 4:49-65. [PMID: 20694065 PMCID: PMC2899786 DOI: 10.2147/ce.s6008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Indexed: 11/29/2022]
Abstract
Introduction: Acute coronary syndromes and non-Q-wave myocardial infarction are often initiated by platelet activation. Eptifibatide is a cyclic heptapeptide and is the third inhibitor of glycoprotein (Gp) IIb/IIIa that has found broad acceptance after the specific antibody abciximab and the nonpeptide tirofiban entered the global market. Gp IIb/IIIa inhibitors act by inhibiting the final common pathway of platelet aggregation, and play an important role in the management of acute coronary syndromes. Aims: This review assesses the evidence for therapeutic value of eptifibatide as a Gp IIb/IIIa inhibitor in patients with acute coronary syndromes. Evidence review: Several large, randomized controlled trials show that eptifibatide as adjunctive therapy to standard care in patients with non-ST segment elevation acute coronary syndrome is associated with a significant reduction in the incidence of death or myocardial infarction. Data are limited regarding the use of eptifibatide in patients with ST segment elevation myocardial infarction. Cost-effectiveness analysis indicates that eptifibatide is associated with a favorable cost-effectiveness ratio relative to standard care. According to US cost-effectiveness analysis about 70% of the acquisition costs of eptifibatide are offset by the reduced medical resource consumption during the first year. Eptifibatide was well tolerated in most of the trials. Bleeding is the most commonly reported adverse event, with most major bleeding episodes occurring at the vascular access site. Major intracranial bleeds, stroke, or profound thrombocytopenia rarely occurred during eptifibatide treatment. Place in therapy: Eptifibatide has gained widespread acceptance as an adjunct to standard anticoagulation therapy in patients with acute coronary syndromes, and may be particularly useful in the management of patients with elevated troponin or undergoing percutaneous coronary interventions.
Collapse
Affiliation(s)
- Ibrahim Shah
- Borgess Heart Institute, Kalamazoo, Michigan, USA
| | | | | | | |
Collapse
|
29
|
Abstract
The role of cell adhesion molecules (CAMs) and extracellular matrix (ECM) proteins in various pathological processes, including angiogenesis, thrombosis, inflammation, apoptosis, cell migration, and proliferation is well documented. These processes can lead to both acute and chronic disease states such as ocular diseases, metastasis, unstable angina, myocardial infarction, stroke, osteoporosis, a wide range of inflammatory diseases, vascular remodeling, and neurodegenerative disorders. A key success in this field was identification of the role of platelet glycoprotein (GP)IIb/IIIa in the prevention and diagnosis of various thromboembolic disorders. The use of soluble adhesion molecules as potential diagnostic markers for acute and chronic leukocyte, platelet, and endothelial cell insult is becoming increasingly common. The development of various therapeutic and diagnostic candidates based on the key role of CAMs, with special emphasis on integrins in various diseases, as well as the structure-function aspects of cell adhesion and signaling of the different CAMs and ECM are highlighted.
Collapse
Affiliation(s)
- Shaker A Mousa
- Pharmaceutical Research Institute at Albany College of Pharmacy and Health Sciences, Rensselaer, NY, USA
| |
Collapse
|
30
|
Megakaryocyte impairment by eptifibatide-induced antibodies causes prolonged thrombocytopenia. Blood 2009; 114:1250-3. [PMID: 19429867 DOI: 10.1182/blood-2009-02-203034] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Glycoprotein (GP) IIbIIIa inhibitors are used in the treatment of acute coronary syndromes. Transient immune-mediated acute thrombocytopenia is a recognized side effect of GPIIbIIIa inhibitors. We provide evidence that GPIIbIIIa inhibitor-induced antibodies can affect megakaryocytes in the presence of eptifibatide. In a patient with acute coronary syndrome, acute thrombocytopenia occurred after a second exposure to eptifibatide 20 days after the initial treatment. Despite the short half-life of eptifibatide (t(1/2) = 2 hours), thrombocytopenia less than 5 x 10(9)/L and gastrointestinal and skin hemorrhage persisted for 4 days. Glycoprotein-specific enzyme-linked immunosorbent assay showed eptifibatide-dependent, GPIIbIIIa-specific antibodies. Bone marrow examination showed predominance of early megakaryocyte stages, and platelet transfusion resulted in an abrupt platelet count increase. Viability of cultured cord blood-derived megakaryocytes was reduced in the presence of eptifibatide and patient IgG fraction. These findings can be explained by impaired megakaryocytopoiesis complicating anti-GPIIbIIIa antibody-mediated immune thrombocytopenia. This mechanism may also apply to some patients with autoimmune thrombocytopenia.
Collapse
|
31
|
|
32
|
Pancioli AM, Broderick J, Brott T, Tomsick T, Khoury J, Bean J, del Zoppo G, Kleindorfer D, Woo D, Khatri P, Castaldo J, Frey J, Gebel J, Kasner S, Kidwell C, Kwiatkowski T, Libman R, Mackenzie R, Scott P, Starkman S, Thurman RJ. The combined approach to lysis utilizing eptifibatide and rt-PA in acute ischemic stroke: the CLEAR stroke trial. Stroke 2008; 39:3268-76. [PMID: 18772447 DOI: 10.1161/strokeaha.108.517656] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Multiple approaches are being studied to enhance the rate of thrombolysis for acute ischemic stroke. Treatment of myocardial infarction with a combination of a reduced-dose fibrinolytic agent and a glycoprotein (GP) IIb/IIIa receptor antagonist has been shown to improve the rate of recanalization versus fibrinolysis alone. The combined approach to lysis utilizing eptifibatide and recombinant tissue-type plasminogen activator (rt-PA) (CLEAR) stroke trial assessed the safety of treating acute ischemic stroke patients within 3 hours of symptom onset with this combination. METHODS The CLEAR trial was a National Institutes of Health/National Institute of Neurological Disorders and Stroke-funded multicenter, double-blind, randomized, dose-escalation and safety study. Patients were randomized 3:1 to either low-dose rt-PA (tier 1=0.3 mg/kg, tier 2=0.45 mg/kg) plus eptifibatide (75 microg/kg bolus followed by 0.75 microg/kg per min infusion for 2 hours) or standard-dose rt-PA (0.9 mg/kg). The primary safety end point was the incidence of symptomatic intracerebral hemorrhage within 36 hours. Secondary analyses were performed regarding clinical efficacy. RESULTS Ninety-four patients (40 in tier 1 and 54 in tier 2) were enrolled. The combination group of the 2 dose tiers (n=69) had a median age of 71 years and a median baseline National Institutes of Health Stroke Scale (NIHSS) score of 14, and the standard-dose rt-PA group (n=25) had a median age of 61 years and a median baseline NIHSS score of 10 (P=0.01 for NIHSS score). Fifty-two (75%) of the combination treatment group and 24 (96%) of the standard treatment group had a baseline modified Rankin scale score of 0 (P=0.04). There was 1 (1.4%; 95% CI, 0% to 4.3%) symptomatic intracranial hemorrhage in the combination group and 2 (8.0%; 95% CI, 0% to 19.2%) in the rt-PA-only arm (P=0.17). During randomization in tier 2, a review by the independent data safety monitoring board demonstrated that the safety profile of combination therapy at the tier 2 doses was such that further enrollment was statistically unlikely to indicate inadequate safety for the combination treatment group, the ultimate outcome of the study. Thus, the study was halted. There was a trend toward increased clinical efficacy of standard-dose rt-PA compared with the combination treatment group. CONCLUSIONS The safety of the combination of reduced-dose rt-PA plus eptifibatide justifies further dose-ranging trials in acute ischemic stroke.
Collapse
Affiliation(s)
- Arthur M Pancioli
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267-0769, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Patrono C, Baigent C, Hirsh J, Roth G. Antiplatelet drugs: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:199S-233S. [PMID: 18574266 DOI: 10.1378/chest.08-0672] [Citation(s) in RCA: 346] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This article about currently available antiplatelet drugs is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). It describes the mechanism of action, pharmacokinetics, and pharmacodynamics of aspirin, reversible cyclooxygenase inhibitors, thienopyridines, and integrin alphaIIbbeta3 receptor antagonists. The relationships among dose, efficacy, and safety are thoroughly discussed, with a mechanistic overview of randomized clinical trials. The article does not provide specific management recommendations; however, it does highlight important practical aspects related to antiplatelet therapy, including the optimal dose of aspirin, the variable balance of benefits and hazards in different clinical settings, and the issue of interindividual variability in response to antiplatelet drugs.
Collapse
Affiliation(s)
- Carlo Patrono
- From the Catholic University School of Medicine, Rome, Italy.
| | - Colin Baigent
- Clinical Trial Service Unit, University of Oxford, Oxford, UK
| | - Jack Hirsh
- Hamilton Civic Hospitals, Henderson Research Centre, Hamilton, ON, Canada
| | | |
Collapse
|
34
|
Ye F, Liu J, Winkler H, Taylor KA. Integrin alpha IIb beta 3 in a membrane environment remains the same height after Mn2+ activation when observed by cryoelectron tomography. J Mol Biol 2008; 378:976-86. [PMID: 18405917 DOI: 10.1016/j.jmb.2008.03.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2007] [Revised: 03/01/2008] [Accepted: 03/06/2008] [Indexed: 11/28/2022]
Abstract
Integrins perform the critical function of signalling cell attachment to the extracellular matrix or to other cells. This signalling is done through a structural change propagated bidirectionally across the plasma membrane. Integrin activation has been extensively studied with ectodomain constructs, but the structural change within intact, membrane-bound molecules remains a subject of live debate. Using cryoelectron tomography, we examined the simplest predication of the different integrin activation models, i.e., the change in height of the molecules. Analysis using techniques that compensate for the missing wedge during alignment and averaging and that search for patterns in the structure of the aligned molecular subvolumes extracted from the tomogram reveals that the vast majority of molecules show no dramatic height change upon Mn(2+)-induced activation of membrane-bound integrins when compared with an inactive integrin control group. Thus, the result is inconsistent with the switchblade activation model.
Collapse
Affiliation(s)
- Feng Ye
- Institute of Molecular Biophysics, Florida State University, Tallahassee, FL 32306-4380, USA
| | | | | | | |
Collapse
|
35
|
Crenshaw BS, Harrington RA, Tcheng JE. Section Review: Cardiovascular & Renal: Novel antiplatelet agents: The glycoprotein IIb/IIIa inhibitors. Expert Opin Investig Drugs 2008. [DOI: 10.1517/13543784.4.11.1033] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
36
|
Keltai M. Platelet aggregation inhibition in acute coronary syndrome. Facts and expectations. Orv Hetil 2008; 149:483-91. [DOI: 10.1556/oh.2008.28290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A szerző áttekinti az akut coronariaszindróma thrombocytaaggregáció-gátló kezelésének jelenlegi gyakorlatát. Ismerteti a thrombocytaaggregáció-gátlásra használt gyógyszereket, azok adagolását és klinikai hasznosságát. Felhívja a figyelmet arra, hogy a III. fázisú vizsgálatokban alkalmazott gyógyszeradagolás az ismételt vizsgálatok során változhat. Mind az acetilszalicilsav, mind pedig a clopidogrel esetében számolni kell csökkent reaktivitással, amit rezisztenciaként is lehet értelmezni. Mivel ennek jelentősége lehet a klinikai hatékonyság vonatkozásában, ezért is fontos lesz a jövőben a thrombocytaaggregáció-gátlásának mérése, betegágy mellett is használható, gyors, megbízható módszerekkel. A dolgozat végén a szerző áttekinti a kifejlesztés alatt álló újabb thrombocytaaggregáció-gátló szereket.
Collapse
|
37
|
Qureshi AI, Hussein HM, Janjua N, Harris-Lane P, Ezzeddine MA. Postprocedure Intravenous Eptifibatide Following Intra-Arterial Reteplase in Patients with Acute Ischemic Stroke. J Neuroimaging 2008; 18:50-5. [DOI: 10.1111/j.1552-6569.2007.00185.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
38
|
Labinaz M, Ho C, Banerjee S, Martin J, Chen S, Mensinkai S. Meta-analysis of clinical efficacy and bleeding risk with intravenous glycoprotein IIb/IIIa antagonists for percutaneous coronary intervention. Can J Cardiol 2007; 23:963-70. [PMID: 17932572 DOI: 10.1016/s0828-282x(07)70858-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Percutaneous coronary intervention (PCI) has become the most common mode of coronary revascularization. Inhibition of platelet aggregation via glycoprotein (GP) IIb/IIIa receptor blockade significantly reduces the acute ischemic complications associated with PCI, but the risk of bleeding may also be increased with these agents. The purpose of the present study was to provide an up-to-date meta-analysis on the clinical efficacy and safety of intravenous GP IIb/IIIa antagonists in patients undergoing PCI. METHODS A comprehensive search was undertaken to identify all randomized trials of GP IIb/IIIa antagonists versus control in patients intended to undergo PCI. Medline, Embase, Biosis, HealthStar and hand searches were performed. The primary outcome was all-cause mortality. Secondary outcomes included myocardial infarction (MI), repeat revascularization, thrombocytopenia and bleeding. OR and their 95% CI were calculated using the random effects model. RESULTS Twenty-one randomized trials were identified, which together included 23,941 patients. The mortality rate at seven days was 0.33% in the GP IIb/IIa group compared with 0.50% in the control group (OR 0.70, 95% CI 0.29 to 1.68); at 30 days, the mortality rate was 0.83% versus 1.21%, respectively (OR 0.72, 95% CI 0.56 to 0.94); at six months, the mortality rate was 1.92% versus 2.33%, respectively (OR 0.85, 95% CI 0.68 to 1.07); and at one year, the mortality rate was 2.61% versus 3.32%, respectively (OR 0.80, 95% CI 0.64 to 1.00). The number needed to treat at 30 days to save one life was 296. The mortality benefit appeared to dissipate by six months and was of borderline significance at one year. The incidence of MI in the treatment group compared with the control group was reduced at seven days (4.31% versus 6.97%, respectively; OR 0.59, 95% CI 0.46 to 0.75), at 30 days (4.54% versus 6.46% respectively; OR 0.63, 95% CI 0.54 to 0.74) and at six months (5.73% versus 8.29%; OR 0.65, 95% CI 0.55 to 0.77). Repeat revascularization procedures were also significantly lower in the GP IIb/IIIa group compared with the control group at seven days (2.47% versus 4.44%, respectively; OR 0.43, 95% CI 0.29 to 0.84), at 30 days (3.44% versus 5.19%, respectively; OR 0.66, 95% CI 0.56 to 0.77) and at six months (15.21% versus 17.40%, respectively; OR 0.86, 95% CI 0.78 to 0.94). Overall, the composite of death, MI and repeat revascularization was reduced at all time points. An assessment of risk revealed that the incidence of thrombocytopenia (OR 1.41, 95% CI 1.10 to 1.81) and minor bleeding (OR 1.80, 95% CI 1.47 to 2.21), but not major bleeding (OR 1.29, 95 CI 0.98 to 1.68), was significantly increased in the GP IIb/IIIa group versus the control group. CONCLUSIONS Treatment with GP IIb/IIIa inhibitors in the setting of PCI significantly reduces the rates of 30-day mortality, MI and repeat revascularization procedures. These beneficial effects are achieved at an increased risk of thrombocytopenia and minor bleeding, but not major bleeding.
Collapse
|
39
|
Lee SP, Ataga KI, Zayed M, Manganello JM, Orringer EP, Phillips DR, Parise LV. Phase I study of eptifibatide in patients with sickle cell anaemia. Br J Haematol 2007; 139:612-20. [PMID: 17916103 DOI: 10.1111/j.1365-2141.2007.06787.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The alphaIIbbeta3 antagonist eptifibatide is an effective treatment for patients with acute coronary syndromes (ACS). Platelet reactivity and CD40 ligand (CD40L) may play a role in the pathophysiology of sickle cell anaemia (SCA) similar to that in ACS, suggesting that inhibition of platelet aggregation and CD40L release by eptifibatide may benefit patients with SCA. Following eptifibatide infusion, safety and pharmacodynamic data were obtained from four SCA patients in their non-crisis, steady states. Eptifibatide was well tolerated, with no adverse changes in the haematological, biochemical or coagulation parameters studied. Eptifibatide did not increase plasma levels of platelet factor 4 or beta-thromboglobulin, P-selectin exposure or platelet:leucocyte aggregate formation. Moreover, decreases in platelet aggregation and soluble CD40L (sCD40L) levels achieved in SCA patients were comparable to those observed in the treatment of ACS. Finally, indicators of inflammation, macrophage inflammatory protein-1alpha, tumour necrosis factor-alpha and myoglobin were reduced following eptifibatide infusion, while vasodilation correlatives, matrix metalloproteinases (MMP-2 and MMP-9) and leptin were increased. Based on these phase I results, eptifibatide may benefit SCA patients by inhibiting platelet aggregation, decreasing sCD40L levels and favourably altering plasma levels of inflammatory mediators.
Collapse
Affiliation(s)
- Sheritha P Lee
- Department of Pharmacology, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7365, USA
| | | | | | | | | | | | | |
Collapse
|
40
|
Mousa SA. Cell adhesion molecules: potential therapeutic & diagnostic implications. Mol Biotechnol 2007; 38:33-40. [PMID: 18095189 DOI: 10.1007/s12033-007-0072-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2007] [Accepted: 07/20/2007] [Indexed: 11/24/2022]
Abstract
The role of cell adhesion molecules (CAM) and extracellular matrix proteins (ECM) in various pathological processes including angiogenesis, thrombosis, apoptosis, cell migration & proliferation are well documented. These processes can lead to both acute and chronic disease states such as ocular diseases, metastasis, unstable angina, myocardial infarction, stroke, osteoporosis, a wide range of inflammatory diseases, vascular remodeling, and neurodegenerative disorders. A key success in this field is evident from the potential role of the platelet GPIIb/IIIa integrin in the prevention and diagnosis of various thromboembolic disorders. Additionally, the use of soluble adhesion molecules as potential diagnostic markers for acute and chronic leukocyte, platelet, and endothelial cellular insult are increasingly utilized. The development of various therapeutic and diagnostic candidates based on the key role of CAM, with special emphasis on integrins in various diseases as well as the structure-function aspects of cell adhesion and signaling of the different CAM and ECM are highlighted.
Collapse
Affiliation(s)
- Shaker A Mousa
- The Pharmaceutical Research Institute, Albany College of Pharmacy, 106 New Scotland Avenue, Albany, NY, USA.
| |
Collapse
|
41
|
Midei MG, Coombs VJ, Lowry DR, Drossner MN, Prewitt KC, Wang JC, Loughrey MB, Gottlieb SO. Clinical Outcomes Comparing Eptifibatide and Abciximab in ST Elevation Acute Myocardial Infarction Patients Undergoing Percutaneous Coronary Interventions. Cardiology 2007; 107:172-7. [PMID: 16940721 DOI: 10.1159/000095343] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2006] [Accepted: 04/13/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND Randomized clinical trials comparing glycoprotein IIb-IIIa inhibitors have largely excluded patients with ST segment elevation myocardial infarction (STEMI). METHODS We conducted an open-label, sequential comparison of in-hospital and 6-month clinical outcomes in STEMI patients receiving eptifibatide or abciximab as adjunctive therapy during percutaneous coronary intervention (PCI). Registry data were collected and compared for STEMI patients undergoing PCI and receiving eptifibatide or abciximab over a 3.5-year period. Six-month follow-up, using telephone interviews, included major adverse cardiac events and functional status. RESULTS Baseline characteristics were similar for patients receiving eptifibatide (n = 294) or abciximab (n = 158). No significant differences in hospital clinical outcomes were observed for reinfarction (2 vs. 3% for eptifibatide and abciximab, respectively), repeat revascularization (3 vs. 4%), bleeding complications (8 vs. 12%), congestive heart failure (5 vs. 3%), cerebrovascular accidents (0 vs. 2%), renal failure (2 vs. 3%), and all-cause mortality at discharge (5 vs. 4%). No significant difference was seen between groups in all-cause mortality at 6 months (6.5 vs. 6.4%; hazard ratio 0.976; 95% confidence interval 0.43-2.23; log-rank, p = 0.95). CONCLUSIONS No significant differences were observed in clinical outcomes between STEMI patients receiving eptifibatide or abciximab in the setting of PCI. Considering the substantially lower cost of eptifibatide, these data suggest that eptifibatide can be substituted for abciximab to lower overall medication costs while maintaining beneficial safety and efficacy effects.
Collapse
Affiliation(s)
- Mark G Midei
- Midatlantic Cardiovascular Associates, Baltimore, MD 21204, USA
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Mousa SA. In-vitro efficacy of different platelet glycoprotein IIb/IIIa antagonists and thrombolytics on platelet/fibrin-mediated clot dynamics in human whole blood using thrombelastography. Blood Coagul Fibrinolysis 2007; 18:55-60. [PMID: 17179828 DOI: 10.1097/mbc.0b013e3280116c36] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Suppressing platelet activation improves efficacy of thrombolytic therapy for stroke and acute myocardial infarction. Combination treatment with recombinant tissue plasminogen activator (r-tPA) and glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitor that binds with high affinity to platelets may therefore improve the efficacy of thrombolytic therapy. The effect of platelet GPIIb/IIIa antagonists and/or r-tPA on the dynamics of platelet/fibrin clot formation, strength, and lysis was determined using thrombelastography in human blood under thrombin or tissue factor stimulation. The study utilized platelet GPIIb/IIIa antagonists with high affinity and slow off-rate (Class I) from resting and activated platelets in comparison with Class II antagonists (lower affinity and fast off-rate from platelet GPIIb/IIIa receptors). The combination of the active form of roxifiban (XV459; Class I) or the active form of orbofiban (Class II) with a subeffective concentration of r-tPA resulted in a synergistic effect in clot lysis with roxifiban active form XV459 but not with that of orbofiban at therapeutically achievable concentrations that inhibit human platelet aggregation. These data indicate differential enhanced thrombolysis of low levels of r-tPA with high-affinity Class I but not with low-affinity Class II GPIIb/IIIa antagonists in the absence of anticoagulants.
Collapse
Affiliation(s)
- Shaker A Mousa
- The Pharmaceutical Research Institute at Albany College of Pharmacy, Albany, New York 12208, USA.
| |
Collapse
|
43
|
Abstract
With the central importance of antiplatelet therapy in patients with coronary artery disease and the numerous positive trials with glycoprotein (GP) IIb/IIa inhibitors given intravenously, it was hoped that one could extend the benefit of IIb/IIIa inhibition to long-term treatment. Although the hypothesis that prolonged oral IIb/IIIa inhibition was appealing, many issues have been identified in the initial Phase II trials that would limit the usefulness of these compounds. Variability of the level of platelet inhibition was one major culprit that distinguished the oral compounds from intravenous ones. The problems that arose were that increased bleeding has been seen when levels of platelet inhibition are high (e.g., > 90%) and that, conversely, efficacy would likely be limited when levels of platelet inhibition were low. If further development of this class of drugs is undertaken, formal dosing studies would have to establish an oral dosing strategy that achieves appropriately high (80-95% inhibition) and steady levels of inhibition.
Collapse
Affiliation(s)
- Christopher P Cannon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
| |
Collapse
|
44
|
Fesmire FM, Decker WW, Diercks DB, Ghaemmaghami CA, Nazarian D, Brady WJ, Hahn S, Jagoda AS. Clinical policy: critical issues in the evaluation and management of adult patients with non-ST-segment elevation acute coronary syndromes. Ann Emerg Med 2006; 48:270-301. [PMID: 16934648 DOI: 10.1016/j.annemergmed.2006.07.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
45
|
Aoki T, Harada K, Seki J, Tanaka A, Takasugi H, Motoyama Y. FK633: A Potent and Selective Platelet GPIIb/IIIa Antagonist. ACTA ACUST UNITED AC 2006. [DOI: 10.1111/j.1527-3466.1999.tb00010.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
46
|
Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB, Morrison DA, O'Neill WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol 2006; 47:e1-121. [PMID: 16386656 DOI: 10.1016/j.jacc.2005.12.001] [Citation(s) in RCA: 309] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
47
|
Gurk-Turner C. Glycoprotein IIb/IIIa receptor antagonists: a review of the pivotal trials. Proc (Bayl Univ Med Cent) 2006; 13:179-82. [PMID: 16389375 PMCID: PMC1312303 DOI: 10.1080/08998280.2000.11927665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- C Gurk-Turner
- Department of Pharmacy Services, Baylor University Medical Center, Dallas, Texas 75246, USA
| |
Collapse
|
48
|
Abstract
This article discusses some important issues that may arise in the current usage of composite endpoints as primary endpoints for demonstrating the efficacy of new drugs in clinical trials. The discussion focuses on time-to-event composite endpoints. Issues discussed include validity of a composite endpoint, the often lack of follow-up of patients beyond first event, the analysis of a composite endpoint, its sub-composite and individual component endpoints and their interpretation. Actual published examples in the literature are used to illustrate some of these problems. It is recommended that a clinical trial using a composite endpoint as the primary endpoint should be designed to include patient follow-up beyond the first event if possible. For data collected from such trials, basic formats for tabular presentation of trial data and for results of analysis of the composite endpoint, its sub-composite and individual component endpoints are proposed for transparency and ease of interpretation.
Collapse
Affiliation(s)
- George Y H Chi
- Johnson & Johnson Pharmaceutical Research and Development, L.L.C., Room 2604, 920 Route 202 S., Box 300, Raritan, NJ 08569, USA.
| |
Collapse
|
49
|
Abstract
There have been major advances in our understanding of thrombosis and antithrombotic drugs. This review focuses on the molecular aspects of thrombus formation and antithrombotic therapy. Molecules involved in arterial thrombosis are derived from inflammatory cells in the atherosclerotic plaque and blood platelets. These molecules work in concert to promote plaque instability and thrombogenicity. Thrombus formation on the ruptured plaque is mediated by platelet and coagulation activation. By contrast, molecules involved in venous thrombosis are derived from the activated coagulation cascade. Platelets appear to play a secondary role. The antithrombotic drugs are classified according to their targeted constituents: antiplatelet agents and anticoagulants; the latter are further divided into non-specific anticoagulants, such as vitamin K antagonists and heparin, and direct thrombin inhibitors, including hirudin and argatroban. Currently available antiplatelet agents target glycoprotein IIbIIIa (abciximab, tirofiban, eptifibatide), cyclooxygenase-1 (aspirin) or adenosine diphosphate receptor, P2Y12 (clopidogrel).
Collapse
Affiliation(s)
- Kenneth K Wu
- Biology Division of Hematology and Vascular Research Center, University of Texas Health Science Center, Houston, TX 77030, USA.
| | | |
Collapse
|
50
|
Atwater BD, Roe MT, Mahaffey KW. Platelet glycoprotein IIb/IIIa receptor antagonists in non-ST segment elevation acute coronary syndromes: a review and guide to patient selection. Drugs 2005; 65:313-24. [PMID: 15669877 DOI: 10.2165/00003495-200565030-00002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Platelet glycoprotein (Gp) IIb/IIIa receptor antagonists improve outcomes in patients with acute coronary syndromes without persistent ST-segment elevation, but relative effects depend on appropriate patient selection. Recent data from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines) quality improvement initiative suggests that GpIIb/IIIa antagonists are underused in clinical practice. The relationship between GpIIb/IIIa inhibition and the magnitude of clinical benefit in the setting of acute coronary syndromes is complex. Several key factors should be considered for proper patient selection, including accurate patient risk stratification, incorporation of these agents with an early invasive management strategy and the concomitant use of other anti-thrombotic therapies. Current practice guidelines for the treatment of patients with non-ST-segment elevation acute coronary syndromes support the integration of an early invasive management with optimal pharmacological therapy, including GpIIb/IIIa antagonists.
Collapse
Affiliation(s)
- Brett D Atwater
- Duke Clinical Research Institute, Durham, North Carolina 27705, USA
| | | | | |
Collapse
|