Efficacy and Safety of Unfractionated Heparin Plus Glycoprotein IIb/IIIa Inhibitors During Revascularization for an Acute Coronary Syndrome: A Meta‐Analysis of Randomized Trials Performed With Stents and Thienopyridines

Abstract

Background: Early studies of glycoprotein IIb/IIIa inhibitors (GPIs) demonstrated benefit during percutaneous coronary intervention for acute coronary syndromes (ACS). Since their introduction, the magnitude of benefit of GPIs has become unclear. Hypothesis: We hypothesized that adding a GPI to unfractionated heparin in ACS patients treated with stents and thienopyridines is beneficial. Methods: We searched the MEDLINE, Cochrane, and clinicaltrials.gov databases for randomized clinical trials that studied the use of GPIs during ACS. We required that patients be randomly assigned to unfractionated heparin plus a GPI versus unfractionated heparin plus placebo (or control). Additional inclusion criteria included the use of coronary stents and periprocedural thienopyridines. Outcomes were assessed at 30 days. Random effects DerSimonian-Laird summary risk ratios (RR) and 95% confidence intervals (CIs) were constructed. Results: Sixteen studies with 7611 patients were included. Myocardial infarction was 3.1% with GPI versus 4.4% with control (RR = 0.74; 95% CI, 0.59-0.94, P = 0.014); revascularization, 1.7% versus 2.7% (RR = 0.64; 95% CI, 0.46-0.89, P = 0.008); major bleeding, 2.5% versus 2.1% (RR = 1.21; 95% CI, 0.89-1.63, P = 0.22); minor bleeding, 5.5% versus 4.1% (RR = 1.37; 95% CI, 1.06-1.78, P = 0.016); and mortality, 2.2% versus 2.9% (RR = 0.79; 95% CI, 0.59-1.06, P = 0.12), respectively. Conclusions: Among ACS patients treated with stents and thienopyridines, GPIs were associated with reduced myocardial infarction and revascularization. Minor, but not major bleeding was increased with GPIs. Mortality was similar between the groups.

2018 ESC/EACTS Guidelines on myocardial revascularization

“…674,675 A meta-analysis on this topic revealed no mortality benefit of GP IIb/IIIa treatment and while non-fatal MIs were reduced, (minor) bleeding events were significantly higher when utilizing these agents. 676 Thus, GP IIb/IIIa inhibitors may only be considered in specific 'bail-out' situations including high intraprocedural thrombus burden, slow flow, or no-flow with closure of the stented coronary vessel.…”

Blood cells: an historical account of the roles of purinergic signalling

“…For example, clopidogrel has been used for the prevention of cardiac ischaemic complications in percutaneous coronary intervention [370][371][372]. Clopidogrel has also been reported to enhance periodontal repair in rats through decreased inflammation [373].…”

Acute ST-Segment Elevation Myocardial Infarction: Combined Intracoronary Low Dose Eptifibatide and Thrombus Aspiration

“…This led to the development of a new class of antiplatelet drugs, termed glycoprotein IIb/IIIa inhibitors (GPIs), which were hypothesized to be exquisitely effective in disaggregating the acute coronary thrombus responsible for STEMI. A recent meta-analysis including a little over 10,000 patients confirmed the concept that platelet inhibition beyond that provided by aspirin and thienopyridine with GPIs during elective percutaneous intervention resulted in reduced MI size without a significant increase in major bleeding [1]. The reduction in target vessel revascularization at 30 days was not significant, but there was a significant increase in the rate of minor bleeding (from 1.7% to 3 %) and thrombocyotopenia, but no increase in stroke.…”