Routine Upstream Initiation vs Deferred Selective Use of Glycoprotein IIb/IIIa Inhibitors in Acute Coronary Syndromes

Stone, Gregg W.; Bertrand, Michel E.; Moses, Jeffrey W.; Ohman, E. Magnus; Lincoff, A. Michael; Ware, James H.; Pocock, Stuart J.; McLaurin, Brent T.; Cox, David A.; Jafar, M. Zubair; Chandna, Harish; Hartmann, Franz; Leisch, F; Strasser, Ruth H.; Desaga, Martin; Stuckey, Thomas; Zelman, Richard B.; Lieber, Ira; Cohen, David J.; Mehran, Roxana; White, Harvey D.; Investigators, Acuity Trial

doi:10.1001/jama.297.6.591

Cited by 281 publications

(168 citation statements)

References 36 publications

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“…W metaanalizie 6 RCT, obejmującej 29 570 pacjentów z NSTE-ACS, głównie leczonych zachowawczo, wykazano 9-procentowe RRR pod względem śmiertelności lub MI niezakończonego zgonem w przypadku zastosowania inhibitorów GP IIb/IIIa dodanych do heparyn (10,7% vs. 11,5%; p = 0,02) [196]. U pacjentów poddawanych PCI obserwowano największą korzyść z zastosowania wyżej wymienionej grupy leków [10,5% vs. Nie należy podawać inhibitorów GP IIb/IIIa pacjentom z nieznaną anatomią tętnic wieńcowych III A [198,199] Długotrwałe hamowanie P2Y 12 Podawanie inhibitora P2Y 12 w połączeniu z kwasem acetylosalicylowym przez > rok może być rozważone po uważnej ocenie ryzyka niedokrwienia i krwawienia u danego pacjenta …”

Section: Inhibitory Glikoproteiny Iib/iiiaunclassified

See 1 more Smart Citation

2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

Roffi¹,

Patrono²,

Collet³

et al. 2015

Kardiol Pol

210

165

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Section: Inhibitory Glikoproteiny Iib/iiiaunclassified

“…Wcześniejsze (ang. upstream) a związane z procedurą podawanie leku W badaniu ACUITY poddano ocenie odroczone selektywne podawanie jakiegokolwiek inhibitora GP IIb/IIIa (tylko podczas PCI) z rutynowym wcześniejszym (przed procedurą) stosowaniem wyżej wspomnianego leku u 9207 pacjentów z NSTE-ACS [198]. Odroczona selektywna strategia wiązała .…”

Section: 27unclassified

2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

Roffi¹,

Patrono²,

Collet³

et al. 2015

Kardiol Pol

210

165

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“…Twelve larger randomized studies and metaanalyses (LOE 1) 438 -449 372,424,[491][492][493][494][495] showed worse outcomes, or at least more bleeding and need for transfusion without clinical advantage, with glycoprotein IIb/IIIa inhibitors compared with standard/ alternative procedures. In most of the supporting, as well as neutral and opposing, studies a higher rate of (major) bleedings has been observed.…”

Section: Consensus On Sciencementioning

confidence: 99%

Part 9: Acute Coronary Syndromes

Bossaert

O’Connor²,

Arntz³

et al. 2010

Circulation

103

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These experts reviewed 25 topics related to the acute initial management of acute coronary syndrome (ACS), which was further categorized as unstable angina, non-ST-elevation MI (UA/NSTEMI) and ST-elevation MI (STEMI). Topics were identified based on previous recommendations, emerging science, and clinical importance, using an iterative writing process involving all Task Force members. The Task Force reviewed the evidence specifically related to diagnosis and treatment of ACS in the out-ofhospital setting and the first hours of care in the in-hospital setting, typically in the emergency department (ED). The evidence review took place over several years, with ongoing refinement of recommendations being made as new evidence was published. The purpose of the review was to generate current, evidence-based treatment recommendations for healthcare providers who serve as the initial point of contact for patients with signs and symptoms suggestive of ACS.The following is a summary of the most important changes in recommendations for diagnosis and treatment of ACS since the last ILCOR review in 2005. 1,2• The history and physical examination, initial ECG, and initial serum biomarkers, even when used in combination, cannot be used to reliably exclude ACS in the prehospital and ED settings.• In contrast, chest pain observation protocols are useful in identifying patients with suspected ACS and patients who require admission or may be referred for provocative testing for coronary artery disease (CAD) to identify reversible ischemia. Such strategies also reduce cost by reducing unnecessary hospital admissions and improve patient safety through more accurate identification of NSTEMI and STEMI.• The acquisition of a prehospital 12-lead ECG is essential for identification of STEMI patients before hospital arrival and should be used in conjunction with pre-arrival hospital notification and concurrent activation of the catheter laboratory.• Nonphysicians can be trained to independently interpret 12-lead ECGs for the purpose of identifying patients with STEMI, provided that appropriate and reliable STEMI criteria are used. This skill is of particular value in the prehospital setting where paramedics may independently identify STEMI, thus mitigating over-reliance on ECG transmission.• Computer-assisted ECG interpretation can be used to increase diagnostic accuracy of STEMI diagnosis when used alone or in combination with ECG interpretation by a trained healthcare provider.• STEMI systems of care can be implemented to improve the time to treatment. The following measures have been shown to reduce the time to primary percutaneous coronary intervention (PPCI): institutional commitment, use of a team-based approach, arranging single-call activation of the catheterization laboratory by the emergency physician or prehospital provider, requiring the catheterization laboratory to be ready in 20 minutes, having an experienced cardiologist always available, and providing real-time data feedback.• Intravenous (IV) ␤-blockers should not be give...

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“…4 Similarly, in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial, the relative impact of MI and major bleeding on subsequent mortality rate was comparable regardless of antithrombotic strategy. 5 …”

mentioning

confidence: 99%

Prognostic Modeling of Individual Patient Risk and Mortality Impact of Ischemic and Hemorrhagic Complications

et al. 2010

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Background-Both ischemic and hemorrhagic complications increase mortality rate in acute coronary syndromes. Their frequency and relative importance vary according to individual patient risk profiles. We sought to develop prognostic models for the risk of myocardial infarction (MI) and major bleeding to assess their impact on risk of death and to examine the manner in which alternative antithrombotic regimens affect these risks in individual patients. Methods and Results-The Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial randomized 13 819 patients with acute coronary syndrome to heparin plus a glycoprotein IIb/IIIa inhibitor, bivalirudin plus a glycoprotein IIb/IIIa inhibitor, or bivalirudin alone. By logistic regression, there were 5 independent predictors of MI within 30 days (nϭ705; 5.1%) and 8 independent predictors of major bleeding (nϭ645; 4.7%), only 2 of which were common to both event types. In a covariate-adjusted, time-updated Cox regression model, both MI and major bleeding significantly affected subsequent mortality rate (hazard ratios, 2.7 and 2.9, respectively; both PϽ0.001). Treatment with bivalirudin versus heparin plus a glycoprotein IIb/IIIa inhibitor was associated with a nonsignificant 8% increase in MI and a highly significant 50% decrease in major bleeding. Given the individual patient risk profiles and the fact that bivalirudin prevented Ϸ6 major bleeds for each MI that might occur from its use, the estimated reduction in bleeding was greater than the estimated increase in MI by bivalirudin alone rather than heparin plus a glycoprotein IIb/IIIa inhibitor for nearly all patients. Conclusions-Consideration of the individual patient risk profile for MI and major bleeding and the relative treatment effects of alternative pharmacotherapies permits personalized decision making to optimize therapy of patients with acute coronary syndrome.

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Routine Upstream Initiation vs Deferred Selective Use of Glycoprotein IIb/IIIa Inhibitors in Acute Coronary Syndromes

Cited by 281 publications

References 36 publications

2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

Part 9: Acute Coronary Syndromes

Prognostic Modeling of Individual Patient Risk and Mortality Impact of Ischemic and Hemorrhagic Complications

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