Real-World Safety and Efficacy of Glycoprotein IIb/IIIa Inhibitors during Percutaneous Coronary Intervention
- Volume 20 - Issue 3 - March, 2008
- Posted on: 8/1/08
- 0 Comments
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Percutaneous coronary intervention (PCI) is commonly employed in the management of patients with coronary artery disease (CAD), but the optimal adjunctive pharmacologic strategy for patients undergoing PCI is a frequently debated issue, without an identified consensus of expert opinion.
Anticoagulant and antiplatelet regimens have a significant impact on the benefits, risks, complications and costs of PCI. Appropriate antiplatelet therapy during the periprocedural phase of PCI reduces the incidence of myocardial infarction (MI), urgent target vessel revascularization (TVR) and death.1 However, such therapy may be associated with an increased risk of bleeding complications, including life-threatening events, such as retroperitoneal or intracranial hemorrhage.2 Major bleeding complications may result in increased length of hospital stay, increased cost of hospitalization, and, most importantly, increased mortality.3
A wide variety of anticoagulant and antiplatelet regimens are currently available, creating uncertainty over the ideal adjunctive drug regimen for PCI patients. In extensive clinical investigations, glycoprotein (GP) IIb/IIIa inhibitors, namely abciximab, eptifibatide and tirofiban, have demonstrated the ability to significantly reduce ischemic complications following PCI.4–8 However, the clinical benefits of these drugs have been offset somewhat by an increased risk of bleeding complications. Although the occurrence of bleeding complications can be minimized by the use of low-dose, weight-based heparin, reduction of the GP IIb/IIIa inhibitor dose in the setting of impaired renal function, and early vascular access sheath removal following PCI,9–11 there has been disagreement about whether GP IIb/IIIa inhibition during PCI is necessary in various clinical scenarios. It is also unclear which of the three currently available GP IIb/IIIa inhibitors is preferable with regard to efficacy and safety.
Because of the positive results of numerous randomized clinical trials, GP IIb/IIIa antagonists were frequently used (69–94% of PCI cases) during the years 2000 through 2004 in patients undergoing PCI at our institution (LDS Hospital). Institutional guidelines were developed and followed regarding weight-based heparin dosing, adjustment of the dose of GP IIb/IIIa drugs in patients with renal impairment and vascular access sheath management. We hypothesized that with such guidelines, bleeding complications could be significantly lower than those reported by other investigators who have evaluated the real-world outcomes of GP IIb/IIIa inhibitors in PCI.11,12 Using information obtained prospectively from the dedicated, detailed and extensive computerized catheterization laboratory database at our institution, we performed a retrospective analysis of the safety and efficacy of GP IIb/IIIa inhibition during PCI in a full range of patients who are reflective of those seen in clinical practice.