Suboptimal early inhibition of platelets by treatment with tirofiban and implications for coronary interventions

Abstract

We have found that platelet reactivity determined with the use of flow cytometry immediately before percutaneous coronary intervention (PCI) differentiates patients at high and low risk of adverse cardiac events after the procedure. 1 Kabbani S.S. Watkins M.W. Ashikaga T. Terrien E.F. Holoch P.A. Sobel B.E. Schneider D.J. Platelet reactivity characterized prospectively a determinant of outcome 90 days after percutaneous coronary intervention. Circulation. 2001; 104: 181-186 Crossref PubMed Scopus (141) Google Scholar Suppression of platelet aggregation by treatment with inhibitors of glycoprotein (GP) IIb/IIIa reduces the incidence of adverse cardiac events after PCI. 2 The EPIC InvestigatorsUse of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. The EPIC Investigation. N Engl J Med. 1994; 330: 956-961 Crossref PubMed Scopus (2675) Google Scholar , 3 The EPILOG InvestigatorsPlatelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous revascularization. N Engl J Med. 1997; 336: 1689-1696 Crossref PubMed Scopus (1968) Google Scholar , 4 Tcheng J.E. Harrington R.A. Kottke-Marchant K. Kleiman N.S. Ellis S.G. Kereiakes D.J. Mick M.J. Navetta F.I. Smith J.E. Worley S.J. et al. Multicenter, randomized, double-blind, placebo-controlled trial of the platelet integrin glycoprotein IIb/IIIa blocker Integrelin in elective coronary intervention. IMPACT Investigators. Circulation. 1995; 91: 2151-2157 Crossref PubMed Scopus (276) Google Scholar , 5 IMPACT-II InvestigatorsRandomised placebo-controlled trial of the effect of integrilin on complications of PTCA IMPACT-II. Integrilin to Minimise Platelet Aggregation and Coronary Thrombosis-II. Lancet. 1997; 349: 1422-1428 Abstract Full Text Full Text PDF PubMed Scopus (872) Google Scholar , 6 Kereiakes D.J. Kleiman N.S. Ambrose J. Chen M. Rodriquez S. Palabrica T. Herrmann H.C. Sutton J.M. Weaver W.D. McKee D.B. Fitzpatrick V. Sax F.L. Randomized, double-blind, placebo-controlled dose-ranging study of tirofiban (MK-383) platelet IIb/IIIa blockade in high risk patients undergoing coronary angioplasty. J Am Coll Cardiol. 1996; 27: 536-542 Abstract Full Text PDF PubMed Scopus (205) Google Scholar , 7 The RESTORE InvestigatorsEffects of platelet glycoprotein IIb/IIIa blockade with tirofiban on adverse cardiac events in patients with unstable angina or acute myocardial infarction undergoing coronary angioplasty. Circulation. 1997; 96: 1445-1453 Crossref PubMed Google Scholar , 8 O’Shea J.C. Hafley G.E. Greenberg S. Hasselblad V. Lorenz T.J. Kitt M.M. Strony J. Tcheng J.E. ESPRIT InvestigatorsPlatelet glycoprotein IIb/IIIa integrin blockade with eptifibatide in coronary stent intervention: the ESPRIT trial a randomized controlled trial. JAMA. 2001; 285: 2468-2473 Crossref PubMed Scopus (244) Google Scholar , 9 Topol E.J. Moliterno D.J. Herrmann H.C. Powers E.R. Grines C.L. Cohen D.J. Cohen E.A. Bertrand M. Neumann F.J. Stone G.W. DiBattiste P.M. Demopoulos L. TARGET InvestigatorsComparison of two platelet glycoprotein IIb/IIIa inhibitors, tirofiban and abciximab, for the prevention of ischemic events with percutaneous coronary revascularization. N Engl J Med. 2001; 344: 1888-1894 Crossref PubMed Scopus (706) Google Scholar In the Do Tirofiban And Reo Pro Give similar Efficacy outcome Trial (TARGET), a lower 30-day incidence of the combined end point of death, myocardial infarction, and urgent target vessel revascularization was seen in patients treated with abciximab compared with those who received tirofiban. 9 Topol E.J. Moliterno D.J. Herrmann H.C. Powers E.R. Grines C.L. Cohen D.J. Cohen E.A. Bertrand M. Neumann F.J. Stone G.W. DiBattiste P.M. Demopoulos L. TARGET InvestigatorsComparison of two platelet glycoprotein IIb/IIIa inhibitors, tirofiban and abciximab, for the prevention of ischemic events with percutaneous coronary revascularization. N Engl J Med. 2001; 344: 1888-1894 Crossref PubMed Scopus (706) Google Scholar The present study was designed to determine whether the difference observed reflected suboptimal inhibition of platelet aggregation during the first 2 hours after initiation of treatment with tirofiban. We focused on this interval because our previous investigation has suggested that the extent of inhibition with the 2 agents was similar 6 to 10 hours after initiation of therapy. 10 Holmes M.B. Kabbani S.S. Terrien C.M. Watkins M.W. Sobel B.E. Schneider D.J. Quantification by flow cytometry of the efficacy of and interindividual variation of platelet inhibition induced by treatment with tirofiban and abciximab. Coron Artery Dis. 2001; 12: 245-253 Crossref PubMed Scopus (19) Google Scholar CorrectionAmerican Journal of CardiologyVol. 89Issue 12Preview Full-Text PDF