Net Clinical Benefit of Prehospital Glycoprotein IIb/IIIa Inhibitors in Patients with ST-Elevation Myocardial Infarction and High Risk of Bleeding: Effect of Tirofiban in Patients at High Risk of Bleeding Using CRUSADE Bleeding Score

Volume 24 - Issue 3 - March 2012
Posted on: 2/29/12
0 Comments
6016 reads

Author(s):

Renicus S. Hermanides, MD¹, Jan Paul Ottervanger, MD, PhD¹, Jurrien M. ten Berg, MD, PhD²,
A.T. Marcel Gosselink, MD, PhD¹, Gert van Houwelingen, MD³, Jan-Henk E. Dambrink, MD, PhD¹,
Pieter R. Stella, MD, PhD⁴, Christian Hamm, MD, PhD⁵, Arnoud W.J. van ’t Hof, MD, PhD¹, on behalf of the On-TIME 2 Trial Investigators

High-risk bleeding patients had significantly more often triple-vessel disease and use of an intra-aortic balloon pump (IABP) as compared to low-risk bleeding patients. Furthermore, high-risk bleeding patients had more often an overdosage of UFH (82.5% vs 51.5%; P<.001) and a higher mean activated clotting time (ACT) (189 ± 68 vs 177 ± 60; P=.015) as compared to low-risk bleeding patients, whereas treatment with additional UFH at the cath lab did not differ between groups.

As expected, high-risk bleeding patients had a significantly higher rate of non-CABG related bleeding as compared to low risk patients (6.1% vs 2.9%; P=.009; RR, 2.16; 95% CI, 1.2-3.9). However, in contrast to low-risk bleeding patients, the localization of bleeding in these high-risk patients was mostly access-site related (53.0% vs 32.1%; Table 2).

These ‘vulnerable’ high-risk bleeding patients had a significantly higher rate of 30-day all cause mortality (7.2% vs 0.6%; P<.001; RR, 12.2; 95% CI, 5.2-29.3) and 30-day MACE (11.2% vs 4.3%; P<.001; RR, 2.6; 95% CI, 1.7-4.1) as compared with low-risk bleeding patients.

Effect of tirofiban in both bleeding risk groups on angiographic and clinical outcomes. Table 3 shows the angiographic and clinical outcomes. Early initiation of tirofiban in the high-risk bleeding group significantly decreases ST deviation >3 mm 1 hour post PCI (43.3% vs 58.9%; P=.015; RR, 0.74; 95% CI, 0.57-0.94), whereas no significant difference was found in ST-segment deviation in the low-risk bleeding group. There was no significant difference in initial TIMI 3 flow, final TIMI 3 flow, and myocardial blush grade (MBG) between the study medication groups in the high-risk bleeding group, whereas in the low-risk bleeding group final TIMI 3 flow was less often established in patients with tirofiban pretreatment.