Duration of eptifibatide infusion after percutaneous coronary intervention and outcomes among high-risk patients with non-ST-segment elevation acute coronary syndrome: insights from EARLY ACS

A Double-Blinded Randomized Controlled Trial Comparing Eptifibatide Bolus Only Versus Bolus Plus Infusion In Patients Undergoing Primary Percutaneous Coronary Intervention For ST-Elevation Myocardial Infarction

BACKGROUNDS

The use of eptifibatide combined with heparin during percutaneous coronary intervention (PCI) in patients presenting with ST-elevation myocardial infarction (STEMI) is recommended to be followed by continuous infusion. Recently, there are some suggestions that using bolus only may be sufficient and cost-effective but randomized trials are lacking.

AIMS

The goal of this study was to evaluate these two approaches in a double-blinded randomized control trial.

METHODS

The primary PCI patients who received bolus eptifibatide were randomized to 75 mg IV eptifibatide infusion or placebo blindly. The patients were followed up for the primary outcome of vascular or bleeding complications and secondary outcome of ischemic complications.

RESULTS

330 patients (165 from each group) completed the study. The mean age was 57.67 ± 11.53 years and 77.3 % were male. Major bleeding was seen in 1 patient in each group. Hematoma occurred in 8.5 %. The relative risk of hematoma and ecchymosis in bolus plus infusion group to bolus only group were 0.988 (95 % CI: 0.486-2.006) and 1.032 (95 % CI: 0.729-1.459). Multivariate analysis confirmed no significant differences in the bleeding event. Furthermore, there was no significant difference in in-hospital death or any ischemic events. (Cath lab death: 1.4 % in bolus only vs zero % in the control group, p = 0.217, stent thrombosis was seen in one patient in each group).

CONCLUSION

There were no differences in the risk of access site ecchymosis, hematoma or major bleeding. Ischemic events and stent thrombosis rates were also similar. Our study suggests that using eptifibatide bolus only during PCI of patients with STEMI is safe and can be cost-saving.

Efficacy and Safety of Abbreviated Eptifibatide Treatment in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

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.

Eptifibatide Bolus Dose During Elective Percutaneous Coronary Intervention

Background

Eptifibatide is a platelet glycoprotein IIb/IIIa receptor antagonist used for the prevention of cardiac ischemic complications of percutaneous coronary intervention (PCI). Eptifibatide has been used with bolus dose only or bolus plus infusion in patients undergoing PCI which have shown less complications, but the risk of bleeding has been increased. We aimed to compare the outcome and bleeding rate of bolus dose alone or plus infusion in elective PCI.

Methods

In this quasi-experimental study, we compared the outcome of elective PCI following single bolus dose intracoronary (41 patients) or bolus plus intravenous infusion (19 patients) of eptifibatide. In-hospital and follow-up major adverse cardiac events (MACEs) and bleeding rate were recorded and evaluated between groups.

Results

Both groups were comparable regarding baseline findings. Bolus only compared to bolus plus infusion group had lower in-hospital (19.5% vs. 31.6%) and follow-up MACE (15.4% vs. 17.6%), lower bleeding in-hospital (14.6% vs. 21.1%) and follow-up (2.4% vs. 5.3%) as well as lower mortality rate in hospital (4.9% vs. 15.8%), but higher follow-up mortality (10.3% vs. 0), but the difference was not significant.

Conclusions

We observed no significant difference regarding bleeding or MACE between intracoronary bolus infusion and bolus plus intravenous infusion of eptifibatide. It seems intracoronary bolus infusion of eptifibatide due to use of lower doses is a better choice in elective PCI to prevent post-PCI MACE.

Integrins: Integrating the Biology and Therapy of Cell-cell Interactions

PURPOSE

Although the role of integrins has been described in a variety of diseases, these roles seem to be distinct. To date, no study has attempted to provide links to the various pathways by which such integrins can be involved in these diverse disease settings. The purpose of this review was to address this gap in our knowledge with the hypothesis that there is, in fact, a common pathway by which integrins may function.

METHODS

This article provides an in-depth perspective on the discovery, development, and design of therapeutics that modulate cellular function by targeting integrin:ligand interactions by reviewing the literature on this subject; the review included the most recent results of clinical and subclinical studies. A MEDLINE search was conducted for articles pertaining to the various issues related to integrins, and the most relevant articles are discussed (ie, not only those published in journals with a higher impact factor).

FINDINGS

It seems that the ligation of the integrins with their cognate ligands plays a major role in translating membrane dialogue into biological function. In addition, they also seem to play a major regulatory role that can enhance or inhibit biological function depending on the context within which such receptor:ligand interactions occur and the organ and tissues at which interactions occurs and is manipulated. Those studies that used statistical analyses have been included where appropriate.

IMPLICATIONS

Our findings show that anti-integrin treatment has the potential to become a valid coadjuvant in the treatment of several diseases including cancer, inflammatory diseases, HIv infection and cardiovascular diseases.

Intraoperative Eptifibatide Administration During Urgent Arterial Bypass in Neurosurgery

BACKGROUND

In some cases when risk of occlusion of a blood vessel is greater than risk of bleeding when patients undergo urgent or unplanned bypass during neurosurgery, the use of eptifibatide may be an option. We describe 2 patients who underwent arterial bypass in whom eptifibatide was used successfully intraoperatively during neurosurgery for prevention of bypass occlusion.

CASE DESCRIPTION

The first patient presented with a right middle cerebral artery (MCA) aneurysm with subocclusive stenosis of the M1 branch. After right-sided osteoplastic frontotemporal craniotomy, the MCA bifurcation was exposed with a bifurcational 6-mm aneurysm with a wide neck. Prebifurcation stenosis was found, with yellow calcification of the vessel wall, and postbifurcation calcification was found on the upper M2 branch. Superficial temporal artery-MCA bypass and occlusion of the MCA aneurysm was done. Before the bypass, continuous intravenous infusion of eptifibatide 1 μg/kg/minute was administered. The patient recovered normally without hemorrhage or neurologic deficit. The second patient presented with a left-sided lateral sphenoid wing meningioma. Left-sided frontotemporal craniotomy was performed, and the tumor was completely removed from the arachnoid layer. The temporal M3 branch was invaded by the meningioma. As there was no flow through the invaded segment of the aforementioned artery, termino-terminal M3 arterial anastomosis was done. Continuous intravenous infusion of eptifibatide 1 μg/kg/minute was administered. Indocyanine green angiography showed normal flow through the anastomosis, and the patient recovered normally.

CONCLUSIONS

Future studies are needed to test the safety and potential efficacy of eptifibatide in intraoperative settings.

Usefulness of SYNTAX score II in complex percutaneous coronary interventions in the setting of acute coronary syndrome

BACKGROUND

SYNTAX score II (SS II) integrates anatomical SS with clinical characteristics allowing an individualized prediction of long-term mortality.

AIMS

We sought to assess to evaluate the usefulness of SS II in a real-world acute coronary syndromes (ACS) population with severe coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI).

METHODS

From August 2011 to May 2013, out of 1591 consecutive patients admitted for ACS, 217 (13.6%) showed severe CAD (three-vessel disease and/or left main involvement). Among the latter, 100 patients underwent PCI and were enrolled into the study. SS II was calculated in all patients. One-year clinical follow-up was performed; major adverse cardiac and cerebrovascular events (MACCE) were defined as a composite of death, nonfatal myocardial infarction, stroke, or repeat revascularization.

RESULTS

The median SS II was 29 (range, 14-59). Overall, MACCE occurred in 25% of patients (cardiac death 4%, myocardial infarction 4%, stroke 0%, and repeat revascularization 17%). The 1-year MACCE-free survival was significantly lower in patients with SS (⩾29), than in those with SS II (<29) (64.2% vs. 87.2%, respectively; p = 0.007). In multivariate Cox regression analysis, the presence of unprotected left main stenosis [hazard ratio 2.52, 95% confidence interval (CI): 1.02-5.85; p = 0.031] and SS II ⩾29 (hazard ratio 2.74, 95% CI: 1.30-8.21; p = 0.011) were the only predictors of MACCE at 1-year clinical follow-up. The c-index of SS score II was 0.70 (95% CI: 0.58-0.81). For patients who experienced MACCE, the SS II reclassification improved by 36%, while in nonevent patients the reclassification improved by 22%. The net reclassification index was 0.24 (p = 0.09).

CONCLUSION

SS II might represent a useful tool to predict clinical events in not only ideal stable patients, but also an unrestricted, real world population of patients with ACS and severe CAD undergoing PCI.

Effect of a shortened-duration Eptifibatide infusion (75 mg) as adjunctive therapy for percutaneous coronary intervention on in-hospital cardiovascular outcomes and bleeding

A retrospective cohort analysis was conducted on patients who underwent percutaneous coronary intervention (PCI) before and after a practice change which reduced the infusion duration of eptifibatide from 18 hours to the time required for completion of a single vial of 75 mg initiated during PCI. Primary end points were inhospital cardiovascular events, target vessel revascularization, and major or minor bleeding. The secondary end point was drug cost. A total of 1,647 patients received the standard-duration infusion (18 hours), and 1,237 received the short-duration infusion. The median infusion times were 18.1 hours (interquartile range 17.7 to 18.7) and 6.6 hours (interquartile range 5.6 to 11.3) in the standard- and short-duration groups, respectively. No differences were found for the rate of inhospital cardiovascular events (2.0% vs 1.9%, respectively; p = 0.78) or inhospital revascularization (0.2% vs 0.3%, respectively; p = 0.68). Also, no statistically significant difference was observed in major bleeding (standard 4.3% vs short 4.4%; p = 0.94) or minor bleeding (standard 3.3% vs short 2.3%; p = 0.09). In conclusion, using a shortened infusion reduced eptifibatide use by an average of 1.6 vials at cost savings of $823 per patient and resulted in no difference in inhospital cardiovascular events, revascularization, or bleeding.