Unstable angina non ST elevation myocardial infarction GPIIb/IIIa inhibitor
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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:
- Abciximab is not recommended if PCI is not planned. Eptifibatide and Tirofiban are preferred agents when delay in coronary angiography and PCI is anticipated.
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:
- A major side effect of GP IIb/IIIa inhibitors is thrombocytopenia and hence increased bleeding. Therefore, platelet monitoring is indicated during its use.
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
- ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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.