1 / 11

GP IIb/IIIa Inhibition in STEMI: Growing Clinical Trial Evidence

GP IIb/IIIa Inhibition in STEMI: Growing Clinical Trial Evidence. PCI vs fibrinolysis in STEMI patients: Short-term clinical outcomes. Meta-analysis of 23 trials; N = 7739. 25. 20. Frequency (%). 15. 10. 5. 0. Recur ischemia. Death. Death no SHOCK data. ReMI. Total stroke.

nuala
Download Presentation

GP IIb/IIIa Inhibition in STEMI: Growing Clinical Trial Evidence

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. GP IIb/IIIa Inhibition in STEMI: Growing Clinical Trial Evidence

  2. PCI vs fibrinolysis in STEMI patients: Short-term clinical outcomes Meta-analysis of 23 trials; N = 7739 25 20 Frequency (%) 15 10 5 0 Recur ischemia Death Death no SHOCKdata ReMI Total stroke Hem stroke Major bleed Death, MI, stroke PCI Fibrinolysis Antman EM et al. Circulation. 2004;110:588-636. Modified from Keeley EC et al. Lancet. 2003;361:13-20.

  3. PCI vs fibrinolysis in STEMI patients: Long-term clinical outcomes Meta-analysis of 23 trials 35 30 25 Frequency (%) 20 15 10 5 0 Death MI stroke Death Death, no SHOCK data RecurMI Recur ischemia PCI Fibrinolysis Antman EM et al. Circulation. 2004;110:588-636. Modified from Keeley EC et al. Lancet. 2003;361:13-20.

  4. Early presentation (≤3 hours from symptom onset) Invasive strategy not an option Delay to invasive strategy Door-to-balloon exceeds door-to-needle time by >1 hour >90 minutes to balloon time High-volume lab with surgical backup High risk from STEMI Fibrinolysis contraindicated (excessive bleeding/ICH) Late presentation Symptoms >3 hours prior STEMI diagnosis in doubt ACC/AHA STEMI guidelines: Assessing reperfusion options Fibrinolysis Primary PCI ICH = intracranial hemorrhage Antman EM et al. Circulation. 2004;109:2480-6.

  5. TIMI flow grade TIMI 0 Complete occlusion TIMI 1 Penetration of obstruction by contrast but no distal perfusion TIMI 2 Perfusion of entire artery but delayed flow TIMI 3 Full perfusion, normal flow Mortality is reduced with better flow Chesebro JH et al. Circulation. 1987;76:142-54.

  6. Mortality benefit of primary PCI declines with PCI-related time delay Meta-regression analysis of 21 trials 15 Circle sizes reflect study sample size Solid line = weighted meta-regression 10 Absolute risk difference in death (%) P = 0.006 5 62 minutes Benefit:Favors PCI 0 Harm:Favors lytics –5 0 20 40 60 80 100 PCI-related time delay (minutes) Nallamothu BK, Bates ER. Am J Cardiol. 2003;92:824-6.

  7. Major considerations for pharmacologic approaches to facilitate primary PCI • Delay between presentation with STEMI and primary PCI vs progressive nature of ischemia-related necrosis • Inverse relationship between time-to-reperfusion and extent of salvaged myocardium and survival • Relationship between restoration of coronary flow and recovery of contractility and survival after STEMI • Facilitated PCI strategy utilizing GP IIb/IIIa inhibition or fibrinolytic therapy provides a degree of coronary reperfusion when PCI is not immediately available Beygui F, Montalescot G. Eur Heart J. 2005;7(suppl):110-4.

  8. INTAMI pilot trial: Early eptifibatide improves TIMI 3 flow before PCI for STEMI INTegrilin in Acute Myocardial Infarction 80 67.4 70 P = 0.01 58.4 60 50 Patency (%) 40 34.0 30 22.4 20 10.2 7.6 10 0 TIMI 3 TIMI 2 TIMI 0/1 Early administration (n = 53) Late or no administration (n = 49) Zeymer U et al. Eur Heart J. 2005;26:1971-7.

  9. TIMI 3 patency before PCI in trials of early vs late/no GP IIb/IIIa inhibitors in STEMI 40 Abciximab Tirofiban Eptifibatide 30 TIMI 3patency before PCI (%) 20 10 0 Zorman Reo-Mobile ERAMI ReoPro-bridging ADMIRAL Cutlip TIGER-PA On-TIME INTAMI TITAN N = 109 100 69 55 300 60 100 487 102 316 Early Late or no GP IIb/IIIa inhibitor Zeymer U et al. Eur Heart J. 2005;26:1971-7. www.timi.org

  10. GP IIb/IIIa inhibitors for primary PCI 30-day death, recurrent MI, or urgent revascularization P = 0.01 16 14.6 P = 0.03 14 P = 0.02 P = 0.04 11.2 12 10.5 10.5 10 % 8 6 5.8 5 6 4.5 4 2 0 RAPPORT ISAR-2 ADMIRAL* ACE N = 483 401 300 400 Placebo GP IIb/IIIa inhibitor Brener SH et al. Circulation. 1998;98:734-41. Neumann FJ et al. J Am Coll Cardiol. 2000;35:915-21. Montalescot G et al. N Engl J Med. 2001;344:1895-1903. Antoniucci D et al. J Am Coll Cardiol. 2003;42:1879-85. *Outcome also includes stroke

  11. Facilitated PCI in STEMI • Early administration of GP IIb/IIIa inhibitors is associated with significant flow restoration, potentially better myocardial reperfusion, and no significant increase in major bleeding • Early GP IIb/IIIa facilitation strategy may be recommended in STEMI patients who are candidates for primary PCI • Benefits of GP IIb/IIIa therapy in primary PCI for STEMI demonstrated in large clinical trials include improvement in pre-PCI coronary flow, angiographic parameters, and ischemic outcomes and mortality • More data from large-scale clinical trials are needed to determine the risks and benefits of facilitated PCI with GP IIb/IIIa inhibitors + fibrinolytics Beygui F, Montalescot G. Eur Heart JSuppl. 2005;7(suppl I):I10-4.

More Related