Randomized Comparison of Upstream Tirofiban Versus Downstream High Bolus Dose Tirofiban or Abciximab on Tissue-Level Perfusion and Troponin Release in High-Risk Acute Coronary Syndromes Treated With Percutaneous Coronary Interventions

Bolognese, Leonardo; Falsini, Giovanni; Liïstro, Francesco; Angioli, Paolo; Ducci, Kenneth; Taddei, Tamara; Tarducci, R.; Cosmi, Franco; Baldassarre, Silvia; Burali, Antonio

doi:10.1016/j.jacc.2005.11.012

Cited by 89 publications

(47 citation statements)

References 20 publications

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“…This result was supported by many studies which consistently reported better outcomes with upstream or early use of glycoprotein IIb/IIIa inhibitor compared with deferred treatment or other strategies (LOE 1 [452][453][454][455][456][457][458][459][460][461][462][463][464][465][466][467] ; LOE 2 468 -473 ; LOE 3 474 ; LOE 4 [475][476][477][478] ; LOE 5 479 ).…”

Section: Consensus On Sciencementioning

confidence: 74%

Part 9: Acute Coronary Syndromes

Bossaert

O’Connor²,

Arntz³

et al. 2010

Circulation

103

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These experts reviewed 25 topics related to the acute initial management of acute coronary syndrome (ACS), which was further categorized as unstable angina, non-ST-elevation MI (UA/NSTEMI) and ST-elevation MI (STEMI). Topics were identified based on previous recommendations, emerging science, and clinical importance, using an iterative writing process involving all Task Force members. The Task Force reviewed the evidence specifically related to diagnosis and treatment of ACS in the out-ofhospital setting and the first hours of care in the in-hospital setting, typically in the emergency department (ED). The evidence review took place over several years, with ongoing refinement of recommendations being made as new evidence was published. The purpose of the review was to generate current, evidence-based treatment recommendations for healthcare providers who serve as the initial point of contact for patients with signs and symptoms suggestive of ACS.The following is a summary of the most important changes in recommendations for diagnosis and treatment of ACS since the last ILCOR review in 2005. 1,2• The history and physical examination, initial ECG, and initial serum biomarkers, even when used in combination, cannot be used to reliably exclude ACS in the prehospital and ED settings.• In contrast, chest pain observation protocols are useful in identifying patients with suspected ACS and patients who require admission or may be referred for provocative testing for coronary artery disease (CAD) to identify reversible ischemia. Such strategies also reduce cost by reducing unnecessary hospital admissions and improve patient safety through more accurate identification of NSTEMI and STEMI.• The acquisition of a prehospital 12-lead ECG is essential for identification of STEMI patients before hospital arrival and should be used in conjunction with pre-arrival hospital notification and concurrent activation of the catheter laboratory.• Nonphysicians can be trained to independently interpret 12-lead ECGs for the purpose of identifying patients with STEMI, provided that appropriate and reliable STEMI criteria are used. This skill is of particular value in the prehospital setting where paramedics may independently identify STEMI, thus mitigating over-reliance on ECG transmission.• Computer-assisted ECG interpretation can be used to increase diagnostic accuracy of STEMI diagnosis when used alone or in combination with ECG interpretation by a trained healthcare provider.• STEMI systems of care can be implemented to improve the time to treatment. The following measures have been shown to reduce the time to primary percutaneous coronary intervention (PPCI): institutional commitment, use of a team-based approach, arranging single-call activation of the catheterization laboratory by the emergency physician or prehospital provider, requiring the catheterization laboratory to be ready in 20 minutes, having an experienced cardiologist always available, and providing real-time data feedback.• Intravenous (IV) ␤-blockers should not be give...

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Section: Consensus On Sciencementioning

confidence: 74%

Part 9: Acute Coronary Syndromes

Bossaert

O’Connor²,

Arntz³

et al. 2010

Circulation

103

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“…Previous studies of tirofiban have focused mostly on non-ST elevation ACS and their results have sometimes been inconsistent. 7,[15][16][17] The RESTORE investigators have shown in a large group of patients with unstable angina or acute MI that tirofiban reduced major cardiovascular events within 2 days following primary or nonprimary PCI; however, tirofiban did not improve the clinical outcomes or reduce coronary restenosis between day 2 and 6 months following the PCI. 15, 16 The TARGET trial, which also involved patients with unstable angina or non-ST-elevation MI, demonstrated that abciximab was superior to tirofiban in lowering the rates of MI at 30 days and 6 months; however, the 6-month mortality rates were identical for the abciximab and tirofiban groups.…”

Section: Discussionmentioning

confidence: 99%

“…Minor bleeding was defined as a fall in hemoglobin <2.0 mmol/L without the need for a blood transfusion. 7 …”

Section: Evaluation Of Therapeutic Efficacymentioning

confidence: 99%

Effect of Intracoronary Tirofiban in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome

Zhao

Huang

et al. 2008

Circ J

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“…7,8,[13][14][15][16][17][18][19][20][21][22] The main features of each trial are reported in Table 1. Treatment in all trials was on a background of aspirin therapy.…”

Section: Clinical Trialsmentioning

confidence: 99%

Upstream Use of Small-Molecule Glycoprotein IIb/IIIa Inhibitors in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes

Tricoci

Newby

Hasselblad

et al. 2011

Circ: Cardiovascular Quality and Outcomes

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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 (nϭ24 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 (nϭ19 643 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. (Circ Cardiovasc Qual Outcomes. 2011;4:448-458.)

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Randomized Comparison of Upstream Tirofiban Versus Downstream High Bolus Dose Tirofiban or Abciximab on Tissue-Level Perfusion and Troponin Release in High-Risk Acute Coronary Syndromes Treated With Percutaneous Coronary Interventions

Abstract: Among high-risk non-ST-segment-elevation ACS patients treated with an early invasive strategy, upstream tirofiban is associated with improved tissue-level perfusion and attenuated myocardial damage.

Cited by 89 publications

References 20 publications

Part 9: Acute Coronary Syndromes

Part 9: Acute Coronary Syndromes

Effect of Intracoronary Tirofiban in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome

Upstream Use of Small-Molecule Glycoprotein IIb/IIIa Inhibitors in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes

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