Single high-dose bolus tirofiban with high-loading-dose clopidogrel in primary coronary angioplasty

Abstract

Glycoprotein IIb/IIIa inhibitor therapy during primary percutaneous coronary intervention (PCI) decreases the incidence of major adverse cardiac events. These effects directly result from the level of platelet inhibition. It was shown that standard dosing of tirofiban is insufficient for optimal platelet inhibition. We sought to determine the efficacy and safety of single high-dose bolus (HDB) tirofiban with high-dose clopidogrel loading in primary PCI in acute ST elevation myocardial infarction. A total of 100 patients (mean age 55.2 +/- 9.9 years, male/female = 86/14) undergoing primary PCI, pretreated with clopidogrel (450 mg) and aspirin (325 mg), were consecutively randomized into two groups. Group I (n = 50) received a standard dose bolus of tirofiban (10 microg/kg/3 min) with 24-h infusion at a rate of 0.15 microg/kg/min. Group II received single HDB tirofiban (25 microg/kg/3 min). The assessed angiographic, clinical, and echocardiographic endpoints were: initial and final Thrombolysis in Myocardial Infarction (TIMI) grade flow (TGF), corrected TIMI frame count (CTFC), ST-segment resolution (STR) at 90 min, in-hospital bleeding complications, echocardiographic left ventricular ejection fraction (LVEF), death, reinfarction, and repeat target vessel revascularization at 1 month. Platelet function inhibition was measured using PFA-100 (Behring-Dade, Liederbach, Germany) with a test cartridge unit containing a membrane coated with 2 microg of equine Type I collagen and 50 microg adenosine diphosphate before, and 10 min, 2, 4, 6, 12, and 24 h after the bolus of the tirofiban in the first 10 cases of each group. There were no significant differences in baseline characteristics between groups. Initial TGF III was more frequent (24% vs 8%, P = 0.029) and the value of CTFC was lower (75 +/- 34 vs 89 +/- 25, P = 0.03) in group II. Postprocedural TGF, CTFC, STR, bleeding complications, and LVEF at 1 month were not different between the two groups. There was a higher rate of reinfarction in group II (8%) compared with group I (2%), but this difference was not statistically significant (P > 0.05). The results of platelet function analyses showed that group II patients had significantly prolonged platelet function assay closure times (299 +/- 6 s) compared with group patients (236 +/- 97 s) at 10 min after the bolus dose (P = 0.04). However, after the first dose between 2 and 24 h, PFA closure times were significantly prolonged in patients with tirofiban infusion. High-dose bolus of tirofiban seems to be safe and more effective than conventional dose at the periprocedural time, whereas continuous infusion of tirofiban may be necessary in the first 24 h before stable and safe antiplatelet status is reached with clopidogrel. However, safety and efficacy of HDB tirofiban and high-loading-dose clopidogrel together with tirofiban infusion requires further studies with a larger population.

Efficacy and safety of tirofiban-supported primary percutaneous coronary intervention in patients pretreated with 600 mg clopidogrel: results of propensity analysis using the Clinical Center of Serbia STEMI Register

“…27 Furthermore, a significant association of the high-dose bolus of tirofiban and a higher rate of preprocedural TIMI-3 blood flow was observed. 28,29 Our register included STEMI patients who presented within 12 h from the onset of symptoms. The mean time from symptoms to first medical contact in our cohort was 2.5 h (range 1.5-4.0 h), and the mean time from first medical contact to balloon was 89-90 min (range 40-148 min).…”

Intra-Arterial Tirofiban Infusion for Partial Recanalization with Stagnant Flow in Hyperacute Cerebral Ischemic Stroke

“…Severe focal vascular narrowing was detected in the M1 mid-portion in all patients. Intraarterially infused tirofiban doses ranged from 0.5 to 1.5 mg, which corresponded to 33 to 100% of the recommended IV high loading dose in percutaneous coronary intervention (25μg/kg) 7 . Improvement of the distal blood flow was rapidly achieved in all patients after IA administration of tirofiban (TICI grade 3 in all patients).…”

Glycoprotein IIb/IIIa Inhibitor (Tirofiban) in Acute ST-Segment Elevation Myocardial Infarction

“…Furthermore, double doses or high bolus doses of tirofiban given before PCI did not translate into better clinical outcomes. 6,7 With the combined use of stents, ADP antagonists, thienopyridines, aspirin, fibrinolytic agents, and now GP IIb/IIIa antagonists, patients with STEMI can benefit from both facilitated and mechanical reperfusion. GP IIb/IIIa inhibitors are but one in the armamentarium that deserves further investigation.…”

“…Numerous trials have evaluated the effect of GP IIb/IIIa inhibitors (tirofiban) on coronary patency, myocardial perfusion, and clinical outcomes in patients with STEMI but yielded conflicting results. [1][2][3][4][5][6][7][8] Favorable trends for clinical outcomes in both short-and long-term follow-up, when treatment is started early before the patient enters the catheterization laboratory, were Studies have shown conflicting results for glycoprotein IIb/IIIa inhibitor (tirofiban) use in ST-segment elevation myocardial infarction (STEMI). The authors aimed to determine if an upstream conventional dose of tirofiban in addition to a standard treatment regimen improved coronary patency and clinical outcomes in patients with STEMI.…”