Administration Of Glycoprotein Research Articles

The impact of primary percutaneous coronary intervention strategies during st-elevation myocardial infarction on the prevalence of coronary microvascular dysfunction

Abstract Introduction Up to 20% of ST-elevation myocardial infarction (STEMI) patients who undergo primary percutaneous coronary intervention (PCI) continue to have persistent angina, which is considered to be a significant side effect of reperfusion therapy and is associated with coronary microvascular dysfunction (CMD). Purpose To determine if there is a correlation between the technique employed in primary PCI in STEMI patients and the prevalence of CMD after reperfusion. Methods This is a prospective single-blinded observational cohort study conducted in a tertiary cardiac care center in the republic of Lithuania. The study enrolled STEMI patients with multivessel coronary artery disease who underwent primary PCI. Three months later, participants underwent staged PCI of their non-culprit vessels and evaluation for CMD. CMD was defined as an index of microcirculatory resistance (IMR) value ≥ 25 U and a coronary flow reserve (CFR) value < 2.5 U. PCI technique, such as direct stenting or conventional stenting (balloon angioplasty followed by stenting), aspiration thrombectomy, and intracoronary glycoprotein IIb/IIIa inhibitor administration, were prospectively documented. We tested for overall differences in patient characteristics and outcomes between groups using Chi-Square (or Kruskal-Wallis) tests and used the Holm-Bonferroni adjustment (or Dunn's tests) for subsequent pairwise tests. We also performed logistic regression. Results 200 patients were enrolled, with 96 (48%) and 104 (52%), respectively, undergoing direct and conventional stenting. The median age was 65.5 [58, 76] years, most patients were men (59.5%) and 46 patients (23%) met criteria for CMD. Baseline characteristics and risk factors were similar between those with and without CMD. Patients who underwent direct stenting were less likely to suffer from CMD compared to those who underwent conventional stenting (10 (10.4%) vs 36 (34.6%); p < 0.001). In the logistic multivariable analysis, direct stenting, aspiration thrombectomy, and administrations of glycoprotein IIb/IIIa had a ROC AUC of 0.765, indicating good predictive ability. In this particular model, direct stenting, aspiration thrombectomy, and the administration of an intracoronary glycoprotein IIb/IIIa inhibitor were associated with decreased odds of the presence of CMD (OR: 0.193, 95% CI: 0.087-0.430, p < 0.001), (OR: 0.243, 95% CI: 0.086-0.688, p = 0.008), and (OR: 0.200, 95% CI: 0.065-0.620, p = 0.005), respectively. Conclusion In STEMI patients undergoing primary PCI, direct stenting is associated with reduced prevalence of CMD compared with conventional stenting. Furthermore, performing aspiration thrombectomy and administering a glycoprotein IIb/IIIa inhibitor was also associated with a lower prevalence of CMD.Forest plot for the outcome of CMDROC for the model of CMD

Benefits and risks of revascularization in senile coronary artery disease patients: is there any optimal choice?

There has been an increase in the population of elderly patients with coronary artery disease (CAD) in recent years. Elderly and, especially, senile patients typically have comorbid conditions, multivessel coronary artery disease and coronary calcification, which make treatment more challenging. The available data from evidence-based medicine is not enough to determine the best treatment strategies for elderly patients, because large randomized clinical trials usually do not include elderly individuals with severe comorbidities. In the presented case, an 80-year-old patient with severe calcification and multivessel coronary artery disease experienced recurrent dissection of the left anterior descending artery (LAD) and stent thrombosis of the left main coronary artery (LMCA) during the second phase of percutaneous coronary intervention, which required the implantation of 8 stents and administration of glycoprotein IIb/IIIa inhibitors, leading to the clinical manifestation of gastrointestinal bleeding. An important feature of the presented case was the necessity to implant a large number of stents, which is a risk factor for restenosis. Various issues are discussed in this case, including the choice of optimal management strategy for an 80-year-old patient with multivessel coronary artery disease. Physicians had to make difficult decisions to achieve a balance between potential benefit and risk. In order to improve the management of elderly patients, further research is needed, as well as the accumulation and discussion of clinical data.

Intracoronary versus intravenous glycoprotein IIb/IIIa inhibitors during primary percutaneous coronary intervention in patients with STEMI: a systematic review and meta-analysis

BackgroundIntracoronary (IC) administration of glycoprotein IIb/IIIa inhibitors (GPIs) has been studied as an adjunctive therapy to improve outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention. In this systematic review and meta-analysis, we aimed to evaluate the efficacy and safety of IC administration of GPIs compared with those of intravenous (IV) administration in patients with STEMI.MethodsWe searched the MEDLINE, Embase, and Cochrane CENTRAL databases for relevant studies published before September 21, 2022. In total, 22 randomized controlled trials involving 7,699 patients were included.ResultsThe proportions of patients achieving thrombolysis in myocardial infarction grade 3 flow, myocardial blush grade 2/3, and complete ST-segment resolution were significantly higher in the IC group than in the IV group. Major adverse cardiac events (MACE) (RR: 0.54, 95% CI: 0.37–0.80) and heart failure (RR: 0.48, 95% CI: 0.25–0.91) within 1 month were significantly lower in the IC group than in the IV group; however, after 6 months, no difference was observed in MACE risk. Additionally, the risks of death and bleeding did not differ between the two routes of administration.ConclusionsWhen considering adjunctive GPI administration for patients with STEMI, the IC route may offer greater benefits than the IV route in terms of myocardial reperfusion and reduced occurrence of MACE and heart failure within 1 month. Nonetheless, when making decisions for IC administration of GPIs, the absence of a benefit for bleeding risk and difficulty accessing the administration route should be considered.

Patient characteristics, management, and outcomes of acute myocardial infarction due to unprotected left main stem occlusion: insights from a real-world multicentre registry over a 12-year period

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Acute myocardial infarction (AMI) due to unprotected left main coronary artery (LMCA) occlusion is a potentially life-threatening disease. AMI management has evolved over the past two decades, and mortality has decreased considerably. Though, little information on patient characteristics, management, and mortality trends in the most recent years is available regarding acute unprotected LMCA occlusion. Purpose We aimed to assess trends in patient characteristics, management, and outcomes for acute myocardial infarction due to LMCA occlusion between 2008 and 2020. Methods We conducted a retrospective multicentre registry of patients with AMI with unprotected LMCA occlusion admitted in three tertiary hospitals between 2008 and 2020. Patients were divided according to timeline of presentation, and we sought to compare clinical characteristics, management, and outcomes between a past group (from January 2008 to December 2012) and a contemporary group (from January 2017 to December 2020). Results Of 128 patients with AMI from unprotected LMCA occlusion, 28 were included in the past group [from January 2008 to December 2012 (group 1)] and 48 were included in the contemporary group [from January 2017 to December 2020 (group 2)]. No statistically significant differences in baseline risk factors were found between the two groups, except for hypertension (50.0% in group 1 vs 75.0% in group 2, p=0.027). There was no difference regarding presentation with cardiogenic shock (57.1% vs 64.6%, p=0.520). Median symptom-to-balloon time was high but similar in both groups [180 min (120-300) vs 210 min (120-420), p=0.640]. Radial access was more frequent used in the contemporary group (33.0% vs 10.7%, p=0.028), as well as the administration of glycoprotein IIb/IIIa inhibitors (14.6% vs 12.0%, p=0.004) and the implantation of drug-eluting stents (100% vs 63.2%, p=0.010). The use of mechanical circulatory support device was surprisingly higher in group 1 (82% vs 46%, p=0.002), but the intra-aortic pump balloon (IABP) was the only device available in that group. In the contemporary group, the use of IABP, Impella device, and extracorporeal membrane oxygenation was 37.5%, 20.8%, and 2.1%, respectively. The second antiplatelet agent was also different between groups, with a higher percentage of ticagrelor loading in the contemporary group. In-hospital mortality (46.4% in group 1 vs. 54.2% in group 2, p=0.520) and 1-year cumulative mortality (60.7% vs 60.4%, p=0.741) were high in both groups, but no statistically significant difference was found in survival analysis (p=0.794; log-rank test). Conclusion In our real-world population, despite the use of newer drugs and more advanced devices being more common in the contemporary group, patients with AMI due to LMCA occlusion are still a subpopulation with poor prognosis. Innovative strategies are needed to make a difference.

An Updated Review on Glycoprotein IIb/IIIa Inhibitors as Antiplatelet Agents: Basic and Clinical Perspectives.

The glycoprotein (GP) IIb/IIIa receptor is found integrin present in platelet aggregations. GP IIb/IIIa antagonists interfere with platelet cross-linking and platelet-derived thrombus formation through the competition with fibrinogen and von Willebrand factor. Currently, three parenteral GP IIb/IIIa competitors (tirofiban, eptifibatide, and abciximab) are approved for clinical use in patients affected by percutaneous coronary interventions (PCI) in the location of acute coronary syndrome (ACS). GP IIb/IIIa antagonists have their mechanism of action in platelet aggregation prevention, distal thromboembolism, and thrombus formation, whereas the initial platelet binding to damage vascular areas is preserved. This work is aimed to provide a comprehensive review of the significance of GP IIb/IIIa inhibitors as a sort of antiplatelet agent. Their mechanism of action is based on factors that affect their efficacy. On the other hand, drugs that inhibit GP IIb/IIIa already approved by the FDA were reviewed in detail. Results from major clinical trials and regulatory practices and guidelines to deal with GP IIb/IIIa inhibitors were deeply investigated. The cardiovascular pathology and neuro-interventional surgical application of GP IIb/IIIa inhibitors as a class of antiplatelet agents were developed in detail. The therapeutic risk/benefit balance of currently available GP IIb/IIa receptor antagonists is not yet well elucidated in patients with ACS who are not clinically evaluated regularly for early cardiovascular revascularization. On the other hand, in patients who have benefited from PCI, the antiplatelet therapy intensification by the addition of a GP IIb/IIIa receptor antagonist (intravenously) may be an appropriate therapeutic strategy in reducing the occurrence of risks of thrombotic complications related to the intervention. Development of GP IIb/IIIa inhibitors with oral administration has the potential to include short-term antiplatelet benefits compared with intravenous GP IIb/IIIa inhibitors for long-term secondary preventive therapy in cardiovascular disease. But studies showed that long-term oral administration of GP IIb/IIIa receptor inhibitors has been ineffective in preventing ischemic events. Paradoxically, they have been linked to a high risk of side effects by producing prothrombotic and pro-inflammatory events.

Atypical ST-Segment-Elevation Myocardial Infarction Presentation in Patients With COVID-19 at a High-Volume Center in New York City.

Atypical presentations of ST-segment-elevation myocardial infarction (STEMI) have been reported in patients who have COVID-19. We have seen this occurrence in our center in Bronx, New York, where multitudes of patients sought treatment for the coronavirus. We studied the prevalence of atypical STEMI findings among patients with COVID-19 who presented during the first 2 months of the pandemic. Consistent with previous reports, 4 of our 10 patients with COVID-19 and STEMI had no identifiable culprit coronary lesion; rather, they often had diffuse ST-segment elevations on surface electrocardiograms along with higher levels of D-dimer and inflammatory markers. In contrast, 32 of 33 patients without COVID-19 (97%) had a culprit lesion. The patients with COVID-19 and a culprit lesion more often needed thrombectomy catheterization and administration of glycoprotein IIb/IIIa inhibitors. Our study confirms that patients with COVID-19 often have atypical STEMI presentations, including the frequent absence of a culprit coronary lesion. Our findings can help clinicians prepare for these atypical clinical presentations.

Intracoronary Versus Intravenous Administration of Glycoprotein IIb/IIIa inhibitors in Diabetic Patients Undergoing Primary Percutaneous Coronary Intervention

Background: Previous trials remained inconsistent regarding benefits and possible risks associated with intracoronary (IC) administration compared with intravenous (IV) are still questionable. We aimed at evaluation safety and effectiveness of IC versus IV tirofiban administration during primary percutaneous coronary intervention (PCI) for diabetic patients (DM) presented with acute ST segment elevation myocardial infarction. Methods: This trial included 100 patients who were randomized either IV high bolus plus maintenance or IC high bolus plus maintenance of tirofiban. Both groups were compared for pre and post intervention for myocardial perfusion, cardiac marker and Major composite adverse cardiac event incidence at 30 days were recorded. Results: Incidence of major adverse cardiac events was not different between groups, but Post procedure TIMI flow III and MBG III were significant in IC group with p = 0.45, and 0.21 respectively favoring intracoronary strategy. Peak CK-MB values were lower in IC tirofiban group than IV group, 155.68 ± 121, 192.4 ± 86 respectively with significant (p=0.021). Peak hs-TnT value was significantly were lower in IC tirofiban group [4291 ± 334 ng/dL vs 5342 ± 286 ng/dL in IV group; (p=0.035). ST segment resolution and 30 days LVEF in IC group were significantly higher in IC group than in IV group (p= 0.023) respectively. Conclusion: IC GpIIb/IIIa inhibitors is more effective in improving coronary blood flow and myocardial tissue perfusion in DM after STEMI 30 days post PCI despite the bleeding event and MACE rates showed no significant difference,IC tirofiban group, showed better improvement in LVEF.

Mathematical modeling of the neutrophil production process supported by administration of glycoprotein

Drugs administered in chemotherapy influence the patient's hematopoietic system. The side effects of chemotherapy can force changes in both the dose of drugs and the schedule of their administration, which in turn may adversely affect the patient's health. During chemotherapy treatment, there is a necessity to continuously monitor basic blood parameters, including the number of neutrophils and blood platelets, responsible for the patient's immunity. The aim of this paper is to study the behavior of the hematopoietic system, during chemotherapy, by means of a modified mathematical model of neutrophil production. We conducted simulations for children from 1–15 years old, suffering from neuroblastoma, who are undergoing chemotherapy treatment with Topotecan (TPT). The proposed model provides an effective tool for signaling the moment when the number of mature neutrophils, circulating in the blood, drops below the critical level, that is, 500cells/μL. Such a nadir persisting over time may result in severe neutropenia and consequently require a halt or change to the established treatment schedule. In addition, we analyzed the process of neutrophil production during chemotherapy, supported by the application of glycoprotein as a growth factor of stem cells.

Use of pCONUS HPC for the treatment of unruptured wide-necked bifurcation aneurysms: early clinical experience using single antiplatelet therapy

BackgroundIn recent years, a growing number of stents and stent-like devices have become available to facilitate the treatment of challenging aneurysms. However, the need for dual antiplatelet therapy can limit...

Early experience treating intracranial aneurysms using Accero: a novel, fully visible, low profile braided stent with platinum–nitinol composite wire technology

BackgroundAccero is an innovative, fully visible, self-expanding braided stent with platinum–nitinol composite wire technology, produced by Acandis.ObjectiveTo assess the technical success and safety of this new stent by evaluating the...

Clinical significance of optical coherence tomography-guided angioplasty on treatment selection.

The present study aimed to observe whether optical coherence tomography (OCT)-guided angioplasty is able to provide useful clinical information beyond that obtained by angiography as well as provide recommendations for physicians that may improve treatment selection. This prospective study included 83 patients with coronary artery disease (>18 years) undergoing coronary angiography (CAG) for ST-elevation myocardial infarction (n=13), non-ST-elevation myocardial infarction (n=19), stable angina (n=22), unstable angina (n=10), silent ischemia (n=11), or elective percutaneous coronary intervention (n=8). Following the initial CAG (CAG-pre), the patients underwent OCT before angioplasty (OCT-pre, 24 patients), after angioplasty (OCT-post, 22 patients), or both (37 patients). The thrombus burden, calcification and plaque dissection or rupture were compared between the OCT-pre and CAG-pre recordings. Following angioplasty, stent malapposition, suboptimal stent deployment, suboptimal stent lesion coverage, and edge dissection were compared between OCT-post and CAG-post alone. Among the 83 patients, 45.7% had single-vessel and 54.3% had multiple-vessel disease. OCT pre- and post-angioplasty revealed significantly more information on the procedure than CAG alone. This clinical information changed the clinical strategies in 41/83 (49.4%) patients, including 58 modifications of therapeutic strategy (69.9%, 58/83): Thrombus aspiration in 2 cases (2.4%), administration of glycoprotein IIb/IIIa inhibitors in 8 cases (9.6%), additional balloon inflation in 23 cases (27.7%), additional stent implantation in 17 cases (20.5%), avoiding stent implantation in 4 cases (4.8%), collateral intervention in 2 cases (2.4%), and guidewire reposition in 2 cases (2.4%). In conclusion, OCT-pre and OCT-post provided additional clinical information beyond that obtained by angiography alone, which resulted in modification of the treatment strategies in half of the included patients.

Bivalirudin Anticoagulant Therapy With or Without Platelet Glycoprotein IIb/IIIa Inhibitors During Transcatheter Coronary Interventional Procedures: A Meta-Analysis.

The safety and effectiveness of using the direct thrombin inhibitor bivalirudin during transcatheter coronary interventional procedures remains uncertain.This study aimed to systematically assess anticoagulation with bivalirudin alone or bivalirudin plus glycoprotein (GP) IIb/IIIa inhibitors (bivalirudin-based anticoagulant therapy) in patients undergoing percutaneous coronary intervention (PCI) procedures by a meta-analysis of randomized controlled trials (RCTs).Systematical searches of the MEDLINE, EMBASE, and Cochrane databases were conducted. RCTs comparing bivalirudin-based anticoagulant therapy with a comparable heparin therapy in patients undergoing PCI were eligible. Risk ratios (RRs) with 95% confidence intervals (CIs) served as summary statistics.A total of 38,096 patients from 17 RCTs were randomized to the bivalirudin group (n = 18,878) or heparin group (n = 19,218) in the meta-analysis. No significant differences in death, myocardial infarction or reinfarction, ischemia-driven revascularization, or in-stent thrombosis were observed between the 2 groups (all P > 0.05). Notably, bivalirudin-based therapy showed a highly significant 34% decrease in the incidence of major bleeding (RR = 0.66; 95% CI 0.54-0.81; P < 0.001) and a 28% reduction in the need for blood transfusion (RR = 0.72; 95% CI 0.56-0.91; P < 0.01). Meta-regression analyses demonstrated that additional administration of GP IIb/IIIa receptor inhibitors (P = 0.01), especially eptifibatide (P = 0.001) and tirofiban (P = 0.002), was likely to increase the major bleeding risk associated with bivalirudin.Bivalirudin, in comparison to heparin, is associated with a markedly lower risk of major bleeding, and the additional use of GP IIb/IIIa inhibitors may weaken this benefit.

Appropriate bolus administration of glycoprotein IIb/IIIa inhibitors for patients with acute coronary syndromes undergoing percutaneous coronary intervention: intracoronary or intravenous? A comprehensive and updated meta-analysis and systematic review.

This systematic review with meta-analysis sought to compare the efficacy and safety of intracoronary (IC) vs. intravenous (IV) administration of glycoprotein (GP) IIb/IIIa receptor inhibitors on clinical outcomes following per-cutaneous coronary intervention in patients with acute coronary syndromes (ST-segment elevation myocardial infarction or non-ST-segment-elevation acute coronary syndrome). Medline, Embase, Elsevier, and Sciences online databases as well as Google Scholar literature were used to select appropriate studies with randomised controlled design. The primary end-points were mortality and target vessel revascularisation (TVR), whereas the secondary end points were incidence of thrombolysis in myocardial infarction score 3 flow (TIMI 3 flow means complete perfusion in distal coronary artery bed), re-myocardial infarction (re-MI), major bleeding, stent thrombosis left ventricular ejection fraction (LVEF), and heart failure (HF). The literature search of all major databases retrieved 1006 stud-ies. After screening, a total of 18 trials (5812 patients) were identified with reported outcomes. Pooled analysis showed IC administration of GP IIb/IIIa receptor inhibitors can significantly increase LVEF (WMD 4.97; 95% CI 3.34-6.60; p = 0.000) and the incidence of TIMI 3 flow (OR of 0.77; 95% CI 0.64-0.92; p = 0.005), and significantly decrease in incidence of HF (OR of 1.927; 95% CI 1.189-3.124; p = 0.008). Incidences of TVR, re-MI, major bleeding, stent thrombosis, and mortality showed no significant differences between the IC and IV groups. Overall, the most appropriate route of administration of GP IIb/IIIa inhibitors for patients with acute coronary syndromes appeared to be an IC injection that could increase LVEF and TIMI 3 flow and decrease the incidence of HF. Furthermore, the IC administration was not associated with increased adverse event rates when compared to IV injection.

Activated glycoprotein A repetitions predominant (GARP)–expressing regulatory T cells inhibit allergen-induced intestinal inflammation in humanized mice

Recently, we developed a humanized mouse model of allergen-induced IgE-dependent gut inflammation in PBMC-engrafted immunodeficient mice. In the present study, we wanted to investigate the role of regulatory T (Treg) cells and their activation status in this model. Nonobese diabetic-severe combined immunodeficiency-γc(-/-) mice were injected intraperitoneally with human PBMCs from allergic donors together with the respective allergen or NaCl as control in the presence or absence of different concentrations of CD4(+)CD25(+) Treg cells of the same donor. After an additional allergen boost 1 week later, mice were challenged with the allergen rectally on day 21 and gut inflammation was monitored by a high-resolution video mini-endoscopic system evaluating translucency, granularity, fibrin production, vascularity, and stool. Allergen-specific human IgE in mouse sera, which was detectable only in PBMC plus allergen-treated mice, was strongly inhibited by coinjection of Treg cells at a ratio of at least 1:10. Consequently, the presence of Treg cells significantly decreased IgE-dependent allergen-induced gut inflammation after rectal allergen challenge. In addition, Treg cells reduced allergen-specific proliferation and cytokine production of recovered human CD4(+) T cells in vitro. Activation of Treg cells before injection further increased all inhibitory effects. Prevention of gut inflammation also occurred by the administration of glycoprotein A repetitions predominant, a molecule expressed by activated Treg cells, whereas its blockade completely abrogated inhibition by Treg cells. These results demonstrate that allergen-specific gut inflammation in human PBMC-engrafted mice can be avoided by enhancing the numbers or activity of autologous Treg cells, which is of great interest for therapeutic intervention of allergic diseases of the intestine.

Glycoprotein IIb/IIIa Receptor Inhibitors in Combination With Vorapaxar, a Platelet Thrombin Receptor Antagonist, Among Patients With Non–ST-Segment Elevation Acute Coronary Syndromes (from the TRACER Trial)

We evaluated the interaction between protease-activated receptor-1 antagonist vorapaxar and concomitant glycoprotein (GP) IIb/IIIa receptor inhibitors in patients with non-ST-segment elevation acute coronary syndromes who underwent PCI. In Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome trial, 12,944 patients with non-ST-segment elevation acute coronary syndromes were randomized to vorapaxar or placebo. Administration of GP IIb/IIIa receptor inhibitors was allowed at the treating physician's discretion. We investigated whether use of GP IIb/IIIa receptor inhibitors modified vorapaxar's effect on non-coronary artery bypass grafting (CABG)-related bleeding at 7 days and ischemic events at 30 days. In total, 7,455 patients underwent PCI during index hospitalization. Of these, 2,023 patients (27.1%) received inhibitors and 5,432 (72.9%) did not. Vorapaxar was associated with a numerically higher rate of non-CABG-related moderate/severe Global Use of Strategies to Open Occluded Arteries (GUSTO) bleeding at 7 days compared with placebo in those who did (1.3% vs 1.0%) and did not (0.6% vs 0.4%) receive GP IIb/IIIa receptor inhibitors. Ischemic end point rates at 30 days were not significantly lower with vorapaxar versus placebo. Increased rates of non-CABG GUSTO moderate/severe bleeding were observed in patients who received GP IIb/IIIa receptor inhibitors versus those who did not (adjusted hazard ratio [HR] 1.77, 95% confidence interval [CI] 0.43 to 7.35 in placebo arm; adjusted HR 2.02, 95% CI 0.62 to 6.61 in vorapaxar arm) and in those who received vorapaxar versus placebo (adjusted HR 1.54, 95% CI 0.36 to 6.56 in the GP IIb/IIIa group; adjusted HR 1.34, 95% CI 0.44 to 4.07 in the no-GP IIb/IIIa group). No interaction was found between vorapaxar and inhibitor use up to 7 days (P interaction = 0.89) nor at the end of the treatment (P interaction = 0.74); however, the event rate was low. Also, no interaction was observed for efficacy end points after PCI at 30 days or at the end of the treatment. In conclusion, GP IIb/IIIa receptor inhibitor use plus dual antiplatelet therapy in a population with non-ST-segment elevation myocardial infarction planned for PCI was frequent but did not interact with vorapaxar's efficacy or safety. Nonetheless, GP IIb/IIIa receptor inhibitors and vorapaxar were associated with increased bleeding risk, and their combined use may result in additive effects on bleeding rates.

Antiplatelet therapy and anticoagulation in acute coronary syndrome: current evidence

In recent years, the prognosis of patients with an acute coronary syndrome (ACS) has significantly improved. This can mainly be attributed to the implementation of primary percutaneous coronary intervention (PCI). Apart from mechanical reperfusion, an optimal medical strategy is of great importance. Antiplatelet and antithrombotic therapies in particular play a crucial role in the management of patients with ACS. New options in antiplatelet therapy are more potent P2Y12 inhibitors in addition to acetylsalicylic acid and clopidogrel. Furthermore, anticoagulant therapy before, during and after PCI can be performed by the use of unfractionated heparin, low molecular weight heparins, such as enoxaparin, the synthetic pentasaccharide fondaparinux and the direct thrombin inhibitor bivalirudin with or without additional administration of glycoprotein IIb/IIIa inhibitors. In this article, data on antiplatelet and anticoagulant therapy are presented and the current evidence is discussed.

Intravenous versus intracoronary bolus of glycoprotein IIb/IIIa inhibitor administration during primary percutaneous coronary intervention on long-term left ventricular systolic and diastolic function

In primary percutaneous coronary intervention (PCI), glycoprotein (GP) IIb/IIIa inhibitors are often given in order to attain and maintain better myocardial perfusion. We tested the hypothesis that intracoronary (IC) bolus of GP IIb/IIIa inhibitors might produce a greater improvement in left ventricular (LV) systolic and diastolic function than an intravenous(IV) bolus. Seventy seven patients undergoing primary PCI for their first ST elevation myocardial infarction (STEMI) were randomly assigned to either an IC or IV bolus of GP IIb/IIIa inhibitor, followed by IV infusion. Compared with the echocardiographic findings within 3 days after PCI, LV ejection fraction was higher at 1 year, with no significant differences between the IV and IC groups (IV: 44% vs. 49%, p = 0.001; IC: 43% vs. 48%,p < 0.001). LV diastolic function (E/E') did not significantly change at 1 year by either approach. LV systolic function improved by a similar magnitude following primary PCI, with either IC or IV bolus administration of GP IIb/IIIa inhibitor therapy. However, no significant changes were observed in LV diastolic function.

Does percutaneous coronary intervention in women provide the same results as in men?

Ischemic heart disease shows gender differences, both in terms of clinical characteristics and pathophysiological mechanisms. It is still debated whether these characteristics influence the diagnostic and therapeutic approach and the outcomes in female patients treated with percutaneous coronary intervention. Percutaneous coronary intervention in women has been shown to be feasible, safe and effective as it is in men throughout the whole clinical spectrum of ischemic syndromes. There is a solid scientific evidence of a different diagnostic and therapeutic approach to women suffering from ischemic heart disease compared to men, with a tendency to undertreat female patients, despite the worst risk profile at presentation. Women, in fact, less frequently undergo coronary angiography and receive antiplatelet, antithrombotic or anti-ischemic drugs. They experience more bleedings than men after administration of glycoprotein IIb/IIIa inhibitors. Gender differences, therefore, affect more the clinical than the interventional approach. At least in part, this is due to the fact that current guidelines are based on a male model of diagnostics. It would be desirable to analyze cohorts of patients in whom the percentage of individuals of both sexes will be equally represented, or rather, exclusively female cohorts in order to formulate more targeted diagnostic and therapeutic indications.

Thrombotic arch in ST-segment elevation myocardial infarction: comparison between two-dimensional and three-dimensional optical frequency domain imaging

A 54-year-old female presented with inferoposterior ST-segment elevation myocardial infarction. Coronary angiogram revealed total occlusion of the proximal left circumflex artery. Following a thrombus aspiration, without administration of glycoprotein IIb/IIIa inhibitor, direct stenting with a drug-eluting metallic stent was performed. After stent implantation, angiogram showed thrombolysis in myocardial infarction (TIMI) grade III flow, without any evidence of intraluminal defect …

A Comparison of Intracoronary with Intravenous Glycoprotein IIb/IIIa Inhibitors During Percutaneous Coronary Intervention in Patients with Acute Coronary Syndrome: A Meta‐Analysis of Randomized Controlled Trials

It is still debatable whether intracoronary (IC) administration of glycoprotein IIb/IIIa inhibitors (GPIs) is superior to intravenous (IV) administration for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). We performed a meta-analysis of randomized controlled clinical trials. A literature search was conducted for relevant trials. Primary end-points were short-term (1-3 months) and mid-/long-term (6/12 months) major adverse cardiovascular events (MACEs) (mortality, reinfarction, target vessel revascularization [TVR]). Secondary end-points were thrombolysis in myocardial infarction (TIMI) grade flow, TIMI myocardial perfusion grade (TMPG) flow, left ventricular ejection fraction (LVEF) within 2 weeks, and bleeding complication. Twelve studies were included in the meta-analysis. IC administration of GPIs did not decrease short-term mortality (OR: 0.71, 95% CI: 0.41-1.23, P = 0.22) and reinfarction rate (OR: 0.76, 95% CI: 0.45-1.29, P = 0.31) compared with IV administration. There was a trend toward reduction of short-term TVR rate in IC group compared with IV group but not reaching statistical significance (OR: 0.57, 95% CI: 0.31-1.04, P = 0.07). IC administration of GPIs significantly increased TIMI grade 3 flow (OR: 1.48, 95% CI: 1.06-2.06, P = 0.02) and TMPG grade 2-3 flow (OR: 2.63, 95% CI: 1.53-4.51, P = 0.0004) compared with IV administration. No significant difference was observed in long-term MACEs rate, LVEF, and bleeding complication between the 2 groups. IC administration of GPIs in patients with ACS undergoing PCI can significantly increase target coronary flow and myocardial reperfusion without increasing the risk of bleeding complication, but cannot improve clinical outcome compared with IV administration.