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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.

Publication ,  Journal Article
Tricoci, P; Newby, LK; Hasselblad, V; Kong, DF; Giugliano, RP; White, HD; Théroux, P; Stone, GW; Moliterno, DJ; Van de Werf, F; Armstrong, PW ...
Published in: Circ Cardiovasc Qual Outcomes
July 2011

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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Published In

Circ Cardiovasc Qual Outcomes

DOI

EISSN

1941-7705

Publication Date

July 2011

Volume

4

Issue

4

Start / End Page

448 / 458

Location

United States

Related Subject Headings

  • Tyrosine
  • Tirofiban
  • Survival Analysis
  • Risk
  • Randomized Controlled Trials as Topic
  • Postoperative Complications
  • Platelet Glycoprotein GPIIb-IIIa Complex
  • Platelet Aggregation Inhibitors
  • Peptides
  • Humans
 

Citation

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Tricoci, P., Newby, L. K., Hasselblad, V., Kong, D. F., Giugliano, R. P., White, H. D., … Harrington, R. A. (2011). 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, 4(4), 448–458. https://doi.org/10.1161/CIRCOUTCOMES.110.960294
Tricoci, Pierluigi, L Kristin Newby, Vic Hasselblad, David F. Kong, Robert P. Giugliano, Harvey D. White, Pierre Théroux, et al. “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 4, no. 4 (July 2011): 448–58. https://doi.org/10.1161/CIRCOUTCOMES.110.960294.
Tricoci P, Newby LK, Hasselblad V, Kong DF, Giugliano RP, White HD, et al. 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 Jul;4(4):448–58.
Tricoci, Pierluigi, et al. “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, vol. 4, no. 4, July 2011, pp. 448–58. Pubmed, doi:10.1161/CIRCOUTCOMES.110.960294.
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 Jul;4(4):448–458.

Published In

Circ Cardiovasc Qual Outcomes

DOI

EISSN

1941-7705

Publication Date

July 2011

Volume

4

Issue

4

Start / End Page

448 / 458

Location

United States

Related Subject Headings

  • Tyrosine
  • Tirofiban
  • Survival Analysis
  • Risk
  • Randomized Controlled Trials as Topic
  • Postoperative Complications
  • Platelet Glycoprotein GPIIb-IIIa Complex
  • Platelet Aggregation Inhibitors
  • Peptides
  • Humans