Glycoprotein IIb/IIIa inhibitors: Therapeutic applications in acute ST-segment elevation myocardial infarction
Multiple adjunctive therapies to improve both reperfusion and outcome in AMI have been tested. Early observations from these trials have suggested that complete platelet inhibition with GPIIb/IIIa inhibitors may be a key component in improving reperfusion in patients with AMI. Although platelet inhibition appears to be the focus in many current trials, there is much yet to be learned about optimal strategies for reperfusion in AMI. For example, the role of thrombin inhibition and passivation of the coagulation cascade is not yet completely understood. Primary angioplasty with GPIIb/IIIa inhibitors is an effective reperfusion strategy. However, not all centers can perform early intervention in a timely fashion. GPIIb/IIIa inhibitors do have an effect on reperfusion in AMI but do not provide complete reperfusion in all patients when used alone. The use of GPIIb/IIIa inhibitors in conjunction with reduced-dose thrombolytic therapy appears to have great promise, and early data indicate that this strategy may provide the best reperfusion rates to date. The GUSTO IV trial should provide the definitive answers in the evaluation of the efficacy of combined GPIIb/IIIa inhibitors and fibrinolytic therapy. GUSTO IV AMI will enroll 17,000 patients who present within 6 hours of an AMI and randomize them to receive either conventional r-PA and standard heparin or reduced-dose r-PA, abciximab, and heparin. The end point in this trial will be all-cause mortality at 30 days. Pending final results from GUSTO IV AMI, we should have improved strategies for therapy in AMI. The care of the patient with AMI has improved greatly by evolving new treatment modalities in clinical trials. These have provided insight into the most efficient, most complete, and most reliable means of providing reperfusion therapy. Early observations suggest that combining antiplatelet agents, low-dose fibrinolytic agents, and modest-dose antithrombin agents with a mechanical approach to reperfusion has a great potential in achieving efficient, complete, and reliable reperfusion in AMI.
Campbell, KR; Cantor, W; Sketch, M; Ohman, EM
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