Unstable angina non ST elevation myocardial infarction GPIIb/IIIa inhibitor: Difference between revisions

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(/* ACC / AHA Guidelines for Antiplatelet therapy in Unstable Angina/NSTEMI (DO NOT EDIT) {{cite journal |author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippi...)
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'''Disadvantage of GP IIb/IIIa inhibitors:'''
'''Disadvantage of GP IIb/IIIa inhibitors:'''
*A major side effect of [[GP IIb/IIIa inhibitors]] is [[thrombocytopenia]] and hence increased bleeding. Therefore, platelet monitoring is indicated during its use.
*A major side effect of [[GP IIb/IIIa inhibitors]] is [[thrombocytopenia]] and hence increased bleeding. Therefore, platelet monitoring is indicated during its use.
==ACC / AHA Guidelines for Antiplatelet therapy in Unstable Angina/NSTEMI (DO NOT EDIT) <ref name="pmid21444889">{{cite journal |author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP |title=2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Circulation]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444889 |doi=10.1161/CIR.0b013e31820f2f3e |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444889 |accessdate=2011-03-30}}</ref>==
{{cquote| 
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
'''1.''' Patients with definite [[Unstable angina]] / [[NSTEMI]] at medium or high risk and in whom an initial invasive strategy is selected should receive dual-antiplatelet therapy on presentation. ''(Level of Evidence: A)'' [[ASA]] should be initiated on presentation. ''(Level of Evidence: A)''The choice of a second antiplatelet therapy to be added to ASA on presentation includes 1 of the following:
'''Before PCI:'''
*[[Clopidogrel]] ''(Level of Evidence: B)''; or
*An IV GP IIb/IIIa inhibitor. ''(Level of Evidence: A)'' IV [[eptifibatide]] or [[tirofiban]] are the preferred [[GP IIb/IIIa inhibitors]].
'''At the time of PCI:'''
*[[Clopidogrel]] if not started before [[PCI]] ''(Level of Evidence: A)''; or
*[[Prasugrel]] ''(Level of Evidence: B)''; or
*An IV [[GP IIb/IIIa inhibitor]]. ''(Level of Evidence: A)''
'''2.''' For [[Unstable angina]] / [[NSTEMI]] patients in whom an initial invasive strategy is selected, [[antiplatelet therapy]] in addition to [[aspirin]] should be initiated before diagnostic angiography (upstream) with either [[clopidogrel]] (loading dose followed by daily maintenance dose) or an intravenous [[GP IIb/IIIa inhibitor]]. ''(Level of Evidence: A)'' [[Abciximab]] as the choice for upstream GP IIb/IIIa therapy is indicated only if there is no appreciable delay to angiography and PCI is likely to be performed; otherwise, IV [[eptifibatide]] or [[tirofiban]] is the preferred choice of GP IIb/IIIa inhibitor. ''(Level of Evidence: B)''
'''3.''' For [[Unstable angina]] / [[NSTEMI]] patients in whom an initial conservative strategy is selected, if recurrent symptoms/[[ischemia]], [[HF]], or serious [[arrhythmia]]s subsequently appear, then diagnostic angiography should be performed. (Level of Evidence: A). Either an IV GP IIb/IIIa inhibitor ([[eptifibatide]] or [[tirofiban]] ''[Level of Evidence: A]'') or [[clopidogrel]] (loading dose followed by daily maintenance dose ''[Level of Evidence: B]'') should be added to [[ASA]] and anticoagulant therapy before diagnostic [[angiography]] (upstream). ''(Level of Evidence: C)''
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III: No Benefit]]===
'''1.''' [[Abciximab]] should not be administered to patients in whom [[PCI]] is not planned. ''(Level of Evidence: A)''
'''2.''' In [[Unstable angina]] / [[NSTEMI]] patients who are at low risk for [[ischemic]] events (e.g., [[TIMI risk score ≥2]]) or at high risk of bleeding and who are already receiving [[ASA]] and [[clopidogrel]], upstream [[GP IIb/IIIa inhibitors]] are not recommended. ''(Level of Evidence: B)''
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
'''1.''' For [[Unstable angina]] / [[NSTEMI]] patients in whom an initial conservative strategy is selected and who have recurrent ischemic discomfort with [[clopidogrel]], [[ASA]], and [[anticoagulant therapy]], it is reasonable to add a [[GP IIb/IIIa antagonist]] before [[diagnostic angiography]]. ''(Level of Evidence: C)''
'''2.''' For [[Unstable angina]] / [[NSTEMI]] patients in whom an initial invasive strategy is selected, it is reasonable to omit administration of an IV [[GP IIb/IIIa inhibitor]] if [[bivalirudin]] is selected as the anticoagulant and at least 300 mg of [[clopidogrel]] was administered at least 6 hours earlier than planned catheterization or [[PCI]]. ''(Level of Evidence: B)''
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]===
'''1.''' For [[Unstable angina]] / [[NSTEMI]] patients in whom an initial conservative (i.e., noninvasive) strategy is selected, it may be reasonable to add [[eptifibatide]] or [[tirofiban]] to anticoagulant and oral antiplatelet therapy. ''(Level of Evidence: B)''
'''2.''' The use of upstream [[GP IIb/IIIa inhibitors]] may be considered in high-risk [[Unstable angina]] / [[NSTEMI]] patients already receiving [[ASA]] and a [[thienopyridine]] who are selected for an invasive strategy, such as those with elevated [[troponin]] levels, [[diabetes]], or significant [[ST-segment depression]], and who are not otherwise at high risk for bleeding. ''(Level of Evidence: B)''}}


==See Also==
==See Also==
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*The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>
*The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>
*2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With [[Unstable Angina]] / [[Non–ST-Elevation Myocardial Infarction]] (Updating the 2007 Guideline) <ref name="pmid21444889">{{cite journal |author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP |title=2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Circulation]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444889 |doi=10.1161/CIR.0b013e31820f2f3e |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444889 |accessdate=2011-03-31}}</ref>
*2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With [[Unstable Angina]] / [[Non–ST-Elevation Myocardial Infarction]] (Updating the 2007 Guideline) <ref name="pmid21444889">{{cite journal |author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP |title=2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Circulation]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444889 |doi=10.1161/CIR.0b013e31820f2f3e |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444889 |accessdate=2011-03-31}}</ref>
*2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update)<ref name="pmid22800849">{{cite journal| author=2012 Writing Committee Members. Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR et al.| title=2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2012 | volume= 126 | issue= 7 | pages= 875-910 | pmid=22800849 | doi=10.1161/CIR.0b013e318256f1e0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22800849  }} </ref>


==References==
==References==

Revision as of 13:25, 5 October 2012

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Smita Kohli, M.D.

Glycoprotein IIb/IIIa Inhibitors in the Management of Unstable angina /NSTEMI

Three agents currently available are Abciximab, Eptifibatide and Tirofiban, all three of which are now included by the ACC/AHA guidelines for use in PCI.

Mechanism of action:

  • GP IIb/IIIa inhibitors inhibit the fibrinogen-mediated cross linkage of platelets, which is the final common pathway of platelet aggregation.

Clinical trial data:

  • ISAR-REACT 2 trial[1] studied Abciximab in NSTEMI patients. This was a multicenter, randomized, double-blind, placebo-controlled study enrolling 2022 patients with non-ST-segment elevation ACS undergoing PCI. Results showed that Abciximab reduces the risk of adverse events in patients with non-ST-segment elevation ACS undergoing PCI after pretreatment with 600 mg of clopidogrel.
  • Most recently, EARLY ACS trial[2] revealed that in patients who had acute coronary syndromes without ST-segment elevation, the use of eptifibatide 12 hours or more before angiography was not superior to the provisional use of eptifibatide after angiography. The early use of eptifibatide was associated with an increased risk of non-life-threatening bleeding and need for transfusion. Potential benefit with this class of drugs also led to study of oral GP IIa/IIIb inhibitors.
  • A major study involving Orbofiban(an oral GP IIb/IIIa inhibitor) failed to demonstrate improved outcomes and was associated with increased mortality[3].

Indications:

  • The benefits provided by abciximab appear to be confined to patients presenting with an elevated troponin level.
  • The benefit of GP IIb/IIIa inhibition appears greater when used in high-risk patients and in those with ST segment changes.
  • The benefit was also seen in high risk patients with or without revascularization.

Contraindications:

Dosing:

  • All three agents are for intravenous usage and are given by bolus and continuous infusion.
  • Optimal timing of GP IIb/IIIa inhibition remains controversial with no clear data available from current trials. More so, most of the trials related to timing of GP IIa/IIIb inhibitors involve patients with STEMI and hence cannot be applied to all ACS patients.

Disadvantage of GP IIb/IIIa inhibitors:

See Also

Sources

  • The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction[4]
  • 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina / Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline) [5]
  • 2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update)[6]

References

  1. ↑ Kastrati A, Mehilli J, Neumann FJ; et al. (2006). "Abciximab in patients with acute coronary syndromes undergoing percutaneous coronary intervention after clopidogrel pretreatment: the ISAR-REACT 2 randomized trial". JAMA. 295 (13): 1531–8. doi:10.1001/jama.295.13.joc60034. PMID 16533938. Unknown parameter |month= ignored (help)
  2. ↑ Giugliano RP, White JA, Bode C; et al. (2009). "Early versus delayed, provisional eptifibatide in acute coronary syndromes". N. Engl. J. Med. 360 (21): 2176–90. doi:10.1056/NEJMoa0901316. PMID 19332455. Unknown parameter |month= ignored (help)
  3. ↑ Cannon CP, McCabe CH, Wilcox RG; et al. (2000). "Oral glycoprotein IIb/IIIa inhibition with orbofiban in patients with unstable coronary syndromes (OPUS-TIMI 16) trial". Circulation. 102 (2): 149–56. PMID 10889124. Unknown parameter |month= ignored (help)
  4. ↑ Anderson JL, Adams CD, Antman EM; et al. (2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". JACC. 50 (7): e1–e157. PMID 17692738. Text "doi:10.1016/j.jacc.2007.02.013 " ignored (help); Unknown parameter |month= ignored (help)
  5. ↑ Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP (2011). "2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e31820f2f3e. PMID 21444889. Retrieved 2011-03-31. Unknown parameter |month= ignored (help)
  6. ↑ 2012 Writing Committee Members. Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR; et al. (2012). "2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 126 (7): 875–910. doi:10.1161/CIR.0b013e318256f1e0. PMID 22800849.

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