Clinicians should carefully weigh the risks and benefits of when to administer platelet glycoprotein IIb/IIIa (Gp IIb/IIIa) inhibitors for patients with acute coronary syndromes undergoing invasive treatment, according to a study in the February 14 issue of JAMA.
“In patients with acute coronary syndromes (ACS; unstable angina or non?ST-segment elevation myocardial infarction [MI or heart attack]), an early invasive strategy, consisting of angiography with subsequent triage to either percutaneous coronary intervention (PCI) [such as balloon angioplasty or stent placement to open narrowed arteries], coronary artery bypass graft (CABG) surgery or medical management, results in reduced rates of death and MI compared with conservative care,” the authors provide as background information in the article. “Furthermore, the upstream use of platelet glycoprotein IIb/IIIa (Gp IIb/IIIa) inhibitors (tirofiban or eptifibatide) prior to angiography in patients with ACS further reduces the occurrence of death and MI at 30 days, although at the expense of increased major and minor bleeding complications.” The authors add that current guidelines recommend the use of Gp IIb/IIIa inhibitors (which are potent inhibitors of platelet aggregation that act to decrease blood clotting) in certain patients with ACS undergoing an invasive strategy, either administered upstream prior to angiography in all patients or initiated in the catheterization laboratory selectively to patients undergoing PCI.
Gregg W. Stone, M.D., from Columbia University Medical Center, New York, and colleagues performed the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) Timing trial, a large-scale, randomized trial examining the optimal use strategy of Gp IIb/IIIa inhibitors in 9,207 patients with moderate- and high-risk ACS undergoing an early, invasive treatment strategy at 450 medical centers in 17 countries between Aug. 23, 2003, and Dec. 5, 2005. Patients were randomly assigned to receive either routine upstream (n = 4,605) or deferred selective (n = 4,602) Gp IIb/IIIa inhibitor administration.
“Glycoprotein IIb/IIIa inhibitors were used more frequently (98.3 percent vs. 55.7 percent, respectively) and for a significantly longer duration (median [midpoint], 18.3 vs. 13.1 hours) in patients in the upstream group compared with the deferred group,” the researchers report. “Composite ischemia (death, MI or unplanned revascularization) at 30 days occurred in 7.9 percent of patients assigned to deferred use compared with 7.1 percent of patients assigned to upstream administration (relative risk 1.12 [a non-significant trend toward a 12 percent increase]); as such, the criterion for noninferiority was not met.” The authors add, “?routine upstream compared with deferred selective Gp IIb/IIIa inhibitor use resulted in fewer unplanned revascularization events for ischemia, with no significant differences in the rates of death or MI.” In contrast, deferred use compared with routine upstream use resulted in significantly few major bleeding (4.9 percent vs. 6.1 percent) and minor bleeding events. “The 30-day rates of net clinical outcomes (composite ischemia and major bleeding) were nearly identical between the two strategies.”
“Deferring the routine upstream use of Gp IIb/IIIa inhibitors for selective administration in the cardiac catheterization laboratory only to patients undergoing PCI resulted in a numerical increase in composite ischemia that, while not statistically significant, did not meet the criterion for noninferiority. This was offset by a significant reduction in major bleeding, minor bleeding and blood transfusions. Given emerging data regarding alternative anticoagulant strategies in ACS and evolving understanding of the relative importance of bleeding and ischemic events, clinicians should carefully weigh the risks and benefits of adjunctive pharmacologic strategies in individual patients,” the authors conclude.