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Yeh YT, Hsu JC, Liao PC, Li AH, Liu YH, Chen KC, Chuang W, Ke SR, Chiu YW, Wu YW. Modulators of Mortality Benefit From Peri-Angioplasty Adjunctive Tirofiban in Patients With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Circ J 2021; 85:166-174. [PMID: 33441492 DOI: 10.1253/circj.cj-20-0228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Studies investigating the modulators of mortality benefit conferred by peri-angioplasty glycoprotein IIb/IIIa inhibitors in ST-elevation myocardial infarction (STEMI) are still lacking.Methods and Results:A prospective database (n=1,025) of consecutive cases undergoing primary percutaneous coronary intervention for STEMI was retrospectively analyzed. For patients in Killip class I, II or III, IV, the multivariate-adjusted hazard ratios of 30-day all-cause mortality associated with adjunctive tirofiban were 3.873 (95% CI 0.504-29.745; P=0.193), 0.550 (95% CI 0.188-1.609; P=0.275), and 0.264 (95% CI 0.099-0.704; P=0.008), respectively. The P value for a linear trend was 0.032. Patients who had a body mass index (BMI) within 22.9-25.0 kg/m2had a significant benefit from tirofiban (adjusted HR 0.344; 95% CI 0.145-0.814; P=0.015) compared to other BMI groups. The P value for a quadratic trend was 0.012. A novel Killip-BMI score (KBS = 2.5 × Killip category - | BMI - 24 |) was calculated to select the beneficial population. A KBS ≥2 was associated with significant mortality benefit, whereas a KBS <0 predicted increased 30-day mortality with tirofiban use. CONCLUSIONS Survival benefit from peri-angioplasty tirofiban therapy for STEMI was positively correlated with the Killip class. Tirofiban should be used cautiously in either underweight or overweight patients. The novel KBS used in this study can guide peri-angioplasty use of adjunctive tirofiban in patients with STEMI undergoing primary angioplasty.
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Affiliation(s)
- Yen-Ting Yeh
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Jung-Chung Hsu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Pen-Chih Liao
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Ai-Hsien Li
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Yuan-Hung Liu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Kuo-Chin Chen
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Wenpo Chuang
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Shin-Rong Ke
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Yu-Wei Chiu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital.,Department of Computer Science and Engineering, Yuan Ze University
| | - Yen-Wen Wu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital.,Department of Nuclear Medicine, Far Eastern Memorial Hospital.,National Yang-Ming University School of Medicine.,Department of Nuclear Medicine and Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine
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Drug-Drug Interactions in Acute Coronary Syndrome Patients: Systematic Review. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.2478/sjecr-2019-0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Drug-drug interaction (DDI) is defined as a clinically significant change in the exposure and/or response to a drug caused by co-administration of another drug which may result in a precipitation of an adverse event or alteration of its therapeutic effects. The aim of this systematic review was to provide an overview of DDIs that were actually observed or evaluated in acute coronary syndrome (ACS) patients with particular focus on DDIs with clinical relevance. Electronic searches of the literature were conducted in the following databases: MEDLINE, EBSCO, Scopus, Google Scholar and SCIndeks. A total of 117 articles were included in the review. This review showed that ACS patients can be exposed to a variety of DDIs with diverse outcomes which include decreased efficacy of antiplatelet drugs, thrombolytics or anticoagulants, increased risk of bleeding, rhabdomyolysis, hepatotoxicity, adverse effects on cardiovascular system (e.g. QT interval prolongation, arrhythmias, excessive bradycardia, severe hypotension), serotonin syndrome and drug-induced fever. Majority of the DDIs involved antiplatelet drugs (e.g. aspirin, clopidogrel and ticagrelor). Evidence of some of the reported DDIs is inconclusive as some of the studies have shown conflicting results. There is a need for additional post-marketing and population-based studies to evaluate the true effects of disease states and other factors on the clinical outcomes of DDIs. Clinicians should be attentive to the potential for DDIs and their associated harm in order to minimize or, if possible, avoid medication-related adverse events in ACS patients.
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Galal H, Essmat E. Impact of upstream high bolus dose tirofiban on left ventricular systolic function in patients with acute anterior myocardial infarction treated by primary coronary intervention. Egypt Heart J 2014. [DOI: 10.1016/j.ehj.2014.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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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.
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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
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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.
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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
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Costantino G, Ceriani E, Rusconi AM, Podda GM, Montano N, Duca P, Cattaneo M, Casazza G. Bleeding risk during treatment of acute thrombotic events with subcutaneous LMWH compared to intravenous unfractionated heparin; a systematic review. PLoS One 2012; 7:e44553. [PMID: 22984525 PMCID: PMC3439371 DOI: 10.1371/journal.pone.0044553] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 08/06/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Low Molecular Weight Heparins (LMWH) are at least as effective antithrombotic drugs as Unfractionated Heparin (UFH). However, it is still unclear whether the safety profiles of LMWH and UFH differ. We performed a systematic review to compare the bleeding risk of fixed dose subcutaneous LMWH and adjusted dose UFH for treatment of venous thromboembolism (VTE) or acute coronary syndromes (ACS). Major bleeding was the primary end point. METHODS Electronic databases (MEDLINE, EMBASE, and the Cochrane Library) were searched up to May 2010 with no language restrictions. Randomized controlled trials in which subcutaneous LMWH were compared to intravenous UFH for the treatment of acute thrombotic events were selected. Two reviewers independently screened studies and extracted data on study design, study quality, incidence of major bleeding, patients' characteristics, type, dose and number of daily administrations of LMWH, co-treatments, study end points and efficacy outcome. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated using the random effects model. RESULTS Twenty-seven studies were included. A total of 14,002 patients received UFH and 14,635 patients LMWH. Overall, no difference in major bleeding was observed between LMWH patients and UFH (OR = 0.79, 95% CI 0.60-1.04). In patients with VTE LMWH appeared safer than UFH, (OR = 0.68, 95% CI 0.47-1.00). CONCLUSION The results of our systematic review suggest that the use of LMWH in the treatment of VTE might be associated with a reduction in major bleeding compared with UFH. The choice of which heparin to use to minimize bleeding risk must be based on the single patient, taking into account the bleeding profile of different heparins in different settings.
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Affiliation(s)
- Giorgio Costantino
- Unità Operativa di Medicina Interna II, Dipartimento di Scienze Cliniche L Sacco, Ospedale L Sacco, Università degli Studi di Milano, Milan, Italy.
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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.
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Affiliation(s)
- S H Lang
- Kleijnen Systematic Reviews, Unit 6, Escrick Business Park, Riccall Road, Escrick, York YO19 6FD, UK.
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Pepke W, Eisenreich A, Jaster M, Ayral Y, Bobbert P, Mayer A, Schultheiss HP, Rauch U. Bivalirudin inhibits periprocedural platelet function and tissue factor expression of human smooth muscle cells. Cardiovasc Ther 2011; 31:115-23. [PMID: 22212466 DOI: 10.1111/j.1755-5922.2011.00305.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIM A major concern of stent implantation after percutaneous coronary intervention (PCI) is acute stent thrombosis. Effective inhibition of periprocedural platelet function in patients with coronary artery disease (CAD) leads to an improved outcome. In this study, we examined the periprocedural platelet reactivity after administrating bivalirudin during PCI compared to unfractionated heparin (UFH) administration. Further, the effect of bivalirudin on induced tissue factor (TF) expression in smooth muscle cells (SMC) was determined. METHODS Patients with CAD (n = 58) and double antithrombotic medication were treated intraprocedural with UFH (n = 30) or bivalirudin (n = 28). Platelet activation markers were flow cytometrically measured before and after stenting. The expression of TF in SMC was determined by real-time PCR and Western blotting. The thrombogenicity of platelet-derived microparticles and SMC was assessed via a TF activity assay. RESULTS Bivalirudin significantly diminished the agonist-induced platelet reactivity post-PCI. Compared to UFH treatment, the adenosine diphosphate (ADP) and thrombin receptor-activating peptide (TRAP)-induced thrombospondin expression post-PCI was reduced when bivalirudin was administrated during intervention. In contrast to UFH, bivalirudin reduced the P-selectin expression of unstimulated and ADP-induced platelets post-PCI. Moreover, bivalirudin inhibited the thrombin-, but not FVIIa- or FVIIa/FX-induced TF expression and pro-coagulant TF activity of SMC. Moreover, bivalirudin reduced the TF activity of platelet-derived microparticles postinduction with TRAP or ADP. CONCLUSIONS Bivalirudin is better than UFH in reducing periprocedural platelet activation. Moreover, thrombin-induced TF expression is inhibited by bivalirudin. Thus, bivalirudin seems to be a better anticoagulant during PCI than UFH.
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Affiliation(s)
- Wojciech Pepke
- Charitè - Universitätsmedizin Berlin, Campus Benjamin Franklin, Centrum für Herz- und Kreislaufmedizin, Berlin, Germany
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Tricoci P, Newby LK, Hasselblad V, Kong DF, Giugliano RP, White HD, Théroux P, Stone GW, Moliterno DJ, Van de Werf F, Armstrong PW, Prabhakaran D, Rasoul S, Bolognese L, Durand E, Braunwald E, Califf RM, Harrington RA. Upstream use of small-molecule glycoprotein iib/iiia inhibitors in patients with non-ST-segment elevation acute coronary syndromes: a systematic overview of randomized clinical trials. Circ Cardiovasc Qual Outcomes 2011; 4:448-58. [PMID: 21712522 DOI: 10.1161/circoutcomes.110.960294] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of upstream small-molecule glycoprotein (GP) IIb/IIIa inhibitors in non-ST-segment elevation acute coronary syndromes (NSTE ACS) has been studied in multiple randomized clinical trials. We systematically reviewed the effect of upstream GP IIb/IIIa inhibitor use in NSTE ACS as reported in published clinical trials. METHODS AND RESULTS Randomized clinical trials of upstream small-molecule GP IIb/IIIa inhibitors in NSTE ACS were identified through a PubMed and EMBASE search and were included if they contained 30-day outcome data. Odds ratios were generated from the published data and pooled by means of random effects modeling. The primary outcome measures were 30-day death and 30-day death or myocardial infarction. Primary safety measures were major bleeding and transfusion during the index hospitalization. Twelve clinical trials were included, evaluating tirofiban, eptifibatide, and lamifiban. Of these, 7 evaluated upstream GP IIb/IIIa inhibitors versus placebo (n=24 031) and 5 evaluated a strategy of upstream GP IIb/IIIa inhibitors versus upstream placebo with later provisional use at the time of percutaneous coronary intervention (n=19 643). Overall, upstream GP IIb/IIIa inhibitor use was associated with an 11% reduction in 30-day death/myocardial infarction (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.83 to 0.95) but no significant mortality effect (OR, 0.93; 95% CI, 0.83 to 1.05). The risk of major bleeding was 23% higher in patients treated with upstream GP IIb/IIIa inhibitors (OR, 1.23; 95% CI, 1.02 to 1.48). Results were similar when only trials comparing upstream GP IIb/IIIa inhibitors versus placebo were considered: 30-day death/myocardial infarction (OR, 0.88; 95% CI, 0.81 to 0.95); 30-day death (OR, 0.89; 95% CI, 0.76 to 1.03); and major bleeding (OR, 1.17; 95% CI, 0.88 to 1.54). Upstream versus selective use at percutaneous coronary intervention trended toward lower 30-day death/myocardial infarction (OR, 0.91; 95% CI, 0.82 to 1.01) but had no effect on mortality (OR, 1.00; 95% CI, 0.81 to 1.23) and increased major bleeding risk by 34% (OR, 1.34; 95% CI, 1.10 to 1.63). CONCLUSIONS In NSTE ACS, treatment with upstream small-molecule GP IIb/IIIa inhibitors provides a significant but modest ischemic benefit when compared with initial placebo. Compared with delayed, selective use at percutaneous coronary intervention, early upstream use is associated with a trend toward fewer ischemic events. However, these modest benefits are associated with an increased risk of bleeding.
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Valgimigli M, Biondi-Zoccai G, Tebaldi M, van't Hof AWJ, Campo G, Hamm C, ten Berg J, Bolognese L, Saia F, Danzi GB, Briguori C, Okmen E, King SB, Moliterno DJ, Topol EJ. Tirofiban as adjunctive therapy for acute coronary syndromes and percutaneous coronary intervention: a meta-analysis of randomized trials. Eur Heart J 2009; 31:35-49. [PMID: 19755402 DOI: 10.1093/eurheartj/ehp376] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Marco Valgimigli
- Cardiovascular Institute, Azienda Opedaliera Universitaria di Ferrara, Corso Giovecca 203, Ferrara 44100, Italy.
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Jeong HC, Ahn YK, Jeong MH, Chae SC, Kim JH, Seong IW, Kim YJ, Hur SH, Choi DH, Hong TJ, Yoon JH, Rhew JY, Chae JK, Kim DI, Chae IH, Koo BK, Kim BO, Lee NH, Hwang JY, Oh SK, Cho MC, Kim KS, Jeong KT, Lee MY, Kim CJ, Chung WS, Korea Acute Myocardial Infarction Registry Investigators. Intensive Pharmacologic Treatment in Patients With Acute Non ST-Segment Elevation Myocardial Infarction Who Did Not Undergo Percutaneous Coronary Intervention. Circ J 2008; 72:1403-9. [DOI: 10.1253/circj.cj-08-0048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | | | - Jong Hyun Kim
- Heart Center of Chonnam National University Hospital
| | - In Whan Seong
- Heart Center of Chonnam National University Hospital
| | - Young Jo Kim
- Heart Center of Chonnam National University Hospital
| | - Seung Ho Hur
- Heart Center of Chonnam National University Hospital
| | | | | | - Jung Han Yoon
- Heart Center of Chonnam National University Hospital
| | | | - Jei Keon Chae
- Heart Center of Chonnam National University Hospital
| | - Doo Il Kim
- Heart Center of Chonnam National University Hospital
| | - In Ho Chae
- Heart Center of Chonnam National University Hospital
| | - Bon Kwon Koo
- Heart Center of Chonnam National University Hospital
| | - Byung Ok Kim
- Heart Center of Chonnam National University Hospital
| | - Nae Hee Lee
- Heart Center of Chonnam National University Hospital
| | | | - Seok Kyu Oh
- Heart Center of Chonnam National University Hospital
| | | | - Kee Sik Kim
- Heart Center of Chonnam National University Hospital
| | | | | | - Chong Jin Kim
- Heart Center of Chonnam National University Hospital
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Song Y. Evaluation on the safety and efficacy of tirofiban in the treatment of acute coronary syndrome. ACTA ACUST UNITED AC 2007; 27:142-4. [PMID: 17497280 DOI: 10.1007/s11596-007-0208-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2006] [Indexed: 11/27/2022]
Abstract
To evaluate the safety and efficacy of tirofiban, a specific inhibitor of the platelet glycoprotein llb/llla receptor, in the treatment of unstable angina and myocardial infarction without persistent ST elevation (acute coronary syndrome, ACS), a total of 200 patients were randomly assigned to a heparin group and a tirofiban+heparin group on double-blind basis and the treatment effects of the two protocols on ACS were compared when the patients of both groups were taking aspirin at the same time. The composite primary end-point events consisted of death, myocardial infarction, or refractory ischemia. Our results showed that the frequency of the composite primary end point events in 30 days was lower in tirofiban+heparin group as compared with that of heparin group (13.9% vs 29.3 %, P=0.010). The rates of the other composite end point events in the tirofiban+heparin group were also lower than those in the heparin group in 4.5 days and in 30 days. Bleeding complication occurred in 7.0% of the patients receiving heparin alone and in 12.7% of the patients receiving tirofiban and heparin in combination (P=0.1717). The study showed that the incidence of ischemic events in patients with ACS receiving tirofiban+heparin was lower when compared with that of patients who received only heparin and aspirin, suggesting that tirofiban might be of special value in the treatment of ACS.
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Affiliation(s)
- Yu'e Song
- Department of Cardiology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China.
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Chen SM, Hsieh YK, Guo GBF, Fang CY, Yip HK, Wu CJ, Fu M. Angiographic and clinical outcome in ST-segment elevation myocardial infarction patients receiving an adjunctive double bolus regimen of tirofiban for primary percutaneous coronary intervention. Circ J 2006; 70:536-41. [PMID: 16636486 DOI: 10.1253/circj.70.536] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Because of different dosages, the efficacy of adjunctive tirofiban therapy for primary percutaneous coronary intervention (PCI) is currently unclear. The hypothesis that a double bolus regimen of tirofiban will improve angiographic and clinical outcomes in patients with ST-segment elevation acute myocardial infarction (STEMI) undergoing PCI was tested in the present study. METHODS AND RESULTS Primary PCI was performed in 217 STEMI patients: 80 received standard PCI (control group) and 137 received tirofiban (tirofiban group). Tirofiban was given as a bolus (10 mg/kg) in the emergency room and again upon arrival at the cardiac catheterization laboratory, followed by infusion of 0.15 mg . kg(-1) . min (-1) until the total dose reached 12.5 mg. The primary endpoint was emergency target vessel revascularization, recurrent myocardial infarction, or cardiovascular mortality at 30 days and 1 year. Baseline clinical and angiographic variables of the 2 groups were similar, as were angiographic results after PCI and bleeding complications at 30 days. The primary 30-day and 1-year endpoints were 5.1% and 11.7% in the tirofiban group, respectively, vs 10.0% (p = 0.171) and 18.8% (p = 0.151) in the control group. CONCLUSION Although angiographic and clinical benefits were not demonstrated, the results suggest that research into an effective and uniform dosing regimen of adjunctive tirofiban therapy for PCI is warranted.
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Affiliation(s)
- Shyh-Ming Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, Republic of China
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Kim W, Jeong MH, Hwang SH, Kim KH, Hong YJ, Ahn YK, Kim W, Cho JG, Park JC, Kang JC. Comparison of Abciximab Combined With Dalteparin or Unfractionated Heparin in High-Risk Percutaneous Coronary Intervention in Acute Myocardial Infarction Patients. Int Heart J 2006; 47:821-31. [PMID: 17268117 DOI: 10.1536/ihj.47.821] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The purpose of this study was to determine the clinical outcomes of abciximab combined with the low molecular weight heparin (LMWH), dalteparin, in high-risk percutaneous coronary intervention (PCI) patients with acute myocardial infarction (AMI). A total of 140 high-risk PCI patients with AMI were divided into 2 groups: unfractionated heparin (UFH) with abciximab (group I: 70 patients, 58.7 +/- 10.5 years), and dalteparin with abciximab (group II: 70 patients, 59.6 +/- 9.8 years). Major adverse cardiac events (MACE) during hospitalization and at 4 years after PCI were examined. Baseline clinical characteristics, laboratory findings, echocardiography parameters, and baseline angiographic characteristics were not different between the 2 groups. The incidence of thrombotic total occlusion lesions was 62.9% in both groups. Procedural success was achieved in 91.4% in group I and 90.0% in group II. Bleeding and hemorrhagic events were not different between the 2 groups. No significant intracranial bleeding was observed in either group. The incidence of in-hospital MACE was 7 (10.0%) in group I and 4 (5.7%) in group II. Four-year clinical follow-up was performed in 97% of the patients. Four years after PCI, death occurred in 6 (8.6%) patients in group I and in 7 (10.0%) in group II. MI occurred in 4 (5.7%) and 4 (5.7%), target vessel revascularization (TVR) in 23 (32.9%) and 16 (22.9%), and bypass surgery in 3 (4.3%) and 1 (1.4%), respectively. Overall, a MACE occurred in 33 (47.1%) patients in group I and in 26 (35.1%) patients in group II (P = 0.23). The long-term clinical outcome with dalteparin combined with abciximab may be comparable to that of UFH plus abciximab in high risk PCI patients with AMI.
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Affiliation(s)
- Weon Kim
- Heart Center of Gwangju Veterans Hospital, Gwangju, Korea
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15
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Yip HK, Chang LT, Sun CK, Chen MC, Yang CH, Hung WC, Hsieh YK, Fang CY, Hang CL, Wu CJ, Chang HW. Platelet Activity is a Biomarker of Cardiac Necrosis and Predictive of Untoward Clinical Outcomes in Patients With Acute Myocardial Infarction Undergoing Primary Coronary Stenting. Circ J 2006; 70:31-6. [PMID: 16377921 DOI: 10.1253/circj.70.31] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The relationship between platelet activity and myocardial injury in patients with ST-segment elevated (ST-se) acute myocardial infarction (AMI) remains unclear. This study tested the hypothesis that platelet activity (expressed by CD62p) is enhanced and predictive of both the extent of myocardial damage and 30-day clinical outcome in patients with ST-se AMI undergoing primary coronary stenting. METHODS AND RESULTS Platelet CD62p expression prior to coronary angiographic was prospectively measured using flow cytometry in 45 consecutive patients with AMI undergoing primary coronary stenting. The CD62p expression was also evaluated in 20 healthy and 20 at-risk control subjects. The CD62p expression was significantly higher in AMI patients than in healthy and at-risk control subjects (all p values <0.0001). Patients with high CD62p expression (>or=8%) had significantly higher creatine kinase-MB (p<0.0001) levels, higher incidence of cardiogenic shock (p=0.009) upon presentation, significantly lower left ventricular ejection fraction (p=0.0003), and significantly higher incidence of 30-day composite major adverse clinical outcomes (MACO) (advanced congestive heart failure >or=class 3 or 30-day mortality) (p<0.0001) than those patients with low CD62p expression (<8%). Multiple stepwise logistic regression analysis demonstrated that only high CD62p expression (>or=8%) was an independent predictor of 30-day MACO (all p<0.0001). CONCLUSIONS Platelet activation was significantly increased in patients with ST-se AMI. Initial CD62p expression was independently associated with extent of myocardial damage and 30-day MACO.
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Affiliation(s)
- Hon-Kan Yip
- Division of Cardiology, Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
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Yip HK, Wu CJ, Hang CL, Chang HW, Hung WC, Yeh KH, Yang CH. Serial changes in platelet activation in patients with unstable angina following coronary stenting: evaluation of the effects of clopidogrel loading dose in inhibiting platelet activation. Circ J 2005; 69:1208-11. [PMID: 16195618 DOI: 10.1253/circj.69.1208] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Platelet activation is crucial in the development of acute or subacute stent thrombosis following implantation. This study investigated whether a conventional regimen comprising a loading dose of 300 mg of clopidogrel, followed by daily doses of 75 mg, could significantly suppress platelet activation in patients with unstable angina (UA) undergoing coronary stenting. METHODS AND RESULTS Platelet activation (expressed by CD62p) was serially examined using flow cytometry in 42 consecutive patients with UA who underwent coronary stenting. CD62p expression was also evaluated in 30 normal control subjects. CD62p expression was markedly higher pre-procedure in the study patients than in the normal control subjects (5.2+/-4.0% vs 1.4+/-0.6%, p<0.0001). CD62p expression in the study patients remained significantly higher at 24 h after the procedure than in the control subjects (3.8+/-2.1% vs 1.4+/-0.6%, p<0.001). Additionally, only 26% of CD62p expression (5.2% vs 3.8%, p=0.026) in the study patients was suppressed at 24 h after the procedure. However, more than 60% of CD62p expression (5.2% vs 2.0%, p<0.0001) was suppressed on day 7 after the procedure. CONCLUSION Less than one-third of CD62p expression was suppressed at 24 h by the conventional loading dose (300 mg) of clopidogrel in patients with UA following coronary stenting. This finding indicates the need to evaluate whether an increased loading dose of clopidogrel would be a more efficacious and safe regimen for patients in this clinical setting.
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Affiliation(s)
- Hon-Kan Yip
- Division of Cardiology, Chang Gung Memorial Hospital, Taiwan, ROC
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