Use Of Eptifibatide Research Articles

Results of a pilot clinical trial of the safety and efficacy of an original glycoprotein IIb/IIIa receptor inhibitor in acute coronary syndrome

Aim. To study the safety and efficacy of Angipure in acute ST-segment elevation coronary syndrome (STE-ACS) and high-risk percutaneous transluminal coronary angioplasty (PTCA) compared with eptifibatide.Material and methods. The study included 157 patients with STE-ACS. High-risk PTCA included massive or total coronary artery thrombosis, noreflow/slow-reflow phenomenon, and acute stent thrombosis. Fifty-five people received Angipure at a dose of 0,72 mg/kg, 52 — at a dose of 0,40 mg/kg, while 50 patients received eptifibatide (Integrilin). We conducted clinical and laboratory studies, electrocardiography (ECG), coronary angiography.Results. According to the criteria "Frequency and severity of hemorrhagic events, including hemorrhagic stroke", "Frequency, severity of other adverse events", there were no differences in safety between Angipure at doses of 0,40 and 0,72 mg/kg and eptifibatide. Complaints, clinical symptoms, vital signs, complete blood count, biochemical and coagulation tests, ECG in patients of different groups were similar and had unidirectional dynamics. The use of Angipure or eptifibatide was considered effective if no adverse outcomes (death, recurrent acute ischemic event, need for urgent revascularization) were observed within 30 days. There were no lethal outcomes. One repeated acute ischemic event was registered in each group. In groups of patients receiving Angipure 0,40 mg/kg and eptifibatide, urgent revascularization was required once each.Conclusion. Angipure and eptifibatide have similar safety and efficacy.

Abstract Number: LBA19 Network‐Wide Incidence of Intracranial Hemorrhage in Patients with Acute Ischemic Stroke Receiving Tenecteplase

Introduction Intravenous tenecteplase (TNK) is currently being used as a thrombolytic agent in acute ischemic stroke (AIS) and has has been shown to be non‐inferior to intravenous alteplase according to recent studies. Intracranial hemorrhage (ICH) as a complication of alteplase is approximately at 6%. The aim of our study was to determine the rate of significant ICH in patients receiving TNK indicated for AIS in a real world setting. Methods A network‐wide (3 CSCs, 6 PSCs), multicenter retrospective chart review of patients receiving TNK from February 2020 to January 2022 was performed using the Get With The Guidelines database. TNK bolus dose of 0.25mg/kg was used according to a network‐wide policy. ICH was categorized using ECASS‐3 criteria. Fisher exact test statistic was used to determine if a significant association existed between the presence of ICH and baseline ASPECTS score, endovascular treatment (EVT), and IV eptifibatide use. A benchmark less than 2% PH‐2 incidence was set based on historical alteplase related PH‐2 rates within our network. Social science statistics software was used for data analysis. Results Out of 180 patients who received TNK, 25 subjects (13.89%) developed hemorrhagic transformation. Mean age was 71.88 (95% CI 65.54, 78.22). Forty‐eight percent of subjects were female. Median ASPECTS score was 8 (95% CI 7.54, 8.78). Median 90 day mRS was 3 (95% CI 2.1, 3.9). Hemorrhagic transformation was classified as HI‐1 in 5% (n = 9), HI‐2 in 1.7% (n = 3), PH‐1 in 3.8% (n = 7), and PH‐2 in 3.3% (n = 6) subjects. No significant difference between subjects with other subtypes versus PH‐2 was identified when adjusting for ASPECTS score > = 7 versus < 7 (Fisher value = 1), EVT versus no EVT (Fisher value = 0.65), or use of IV eptifibatide (Fisher value = 0.06). Conclusions Tenecteplase is associated with higher rates of PH‐2 intracranial hemorrhage when compared with our benchmark rates of alteplase‐related PH‐2. This study is significantly limited by small sample size, retrospective nature, and uncontrolled variables. Larger, prospective studies are needed to validate our results.

Abstract Number: LBA16 Does Intracranial Hemorrhage Associated with Tenecteplase Occur Exclusively Within the Stroke Burden?

Introduction As IV tenecteplase (TNK) is becoming an alternative to IV alteplase in acute ischemic stroke (AIS), establishing the incidence of intracranial hemorrhage (ICH) complications is important. Given the higher fibrin specificity of TNK as compared to alteplase, our aim was to distinguish hemorrhage within the stroke burden versus spontaneous ICH in patients with AIS with TNK‐associated ICH. Methods Retrospective chart review of patients presenting from February 2020 to January 2022 with anterior circulation AIS to our comprehensive stroke center who received TNK was performed to evaluate for associated ICH. ECASS‐3 criteria was used to define hemorrhagic transformation and ICH score was used for primary, spontaneous ICH. Fisher exact test statistic was used to evaluate for significant differences in ASPECTS score, medium versus versus large vessel occlusion, angiographic recanalization, IV eptifibatide use, pre‐morbid antiplatelet use, and association with symptomatic versus asymptomatic hemorrhage. A benchmark less than 5% symptomatic ICH incidence was set based on historical alteplase rates within our network. Social science statistics software was used for data analysis. Results Out of 77 subjects who received TNK, 20.7% (n = 16) developed ICH, 9.1% (n = 7) of which were symptomatic ICH with a temporally‐related increase in NIHSS of at least 4 or greater. Seven subjects (43.75%) were male. Mean age was 73.38 (95% CI 65.92, 80.83). Median initial NIHSS was 16, 95% CI [11.74, 21.51]. Median ASPECTS was 9, 95% CI [8.74, 9.89]. Two subjects developed spontaneous, primary ICH (n = 1 symptomatic ICH, n = 1 non‐symptomatic ICH) in the absence of hemorrhagic transformation of ischemic stroke. No significant difference between subjects with asymptomatic hemorrhage versus symptomatic hemorrhage was found when comparing ASPECTS > = 7 versus < 7 (Fisher value = 1), angiographic recanalization (Fisher value = 1), use of IV eptifibatide (Fisher value = 1), pre‐morbid antiplatelet use (Fisher value = 0.13), or medium vessel occlusion (Fisher value = ‐0.63). Conclusions Expected rates of hemorrhagic transformation were higher in tenecteplase than our historical benchmark rate for alteplase. Spontaneous hemorrhage unrelated to ischemic stroke area were seen in 2 subjects without known hematological disorders. Larger, prospective studies are needed to validate safety of tenecteplase in real world settings.

Abstract TP3: Network-wide Incidence Of Intracranial Hemorrhage In Patients With Acute Ischemic Stroke Receiving Tenecteplase

Background: Intravenous tenecteplase (TNK) is currently being used as a thrombolytic agent in acute ischemic stroke (AIS) and has has been shown to be non-inferior to intravenous alteplase according to recent studies. Intracranial hemorrhage (ICH) as a complication of alteplase is approximately at 6%. The aim of our study was to determine the rate of significant ICH in patients receiving TNK indicated for AIS in a real world setting. Methods: A network-wide (3 CSCs, 6 PSCs), multicenter retrospective chart review of patients receiving TNK from February 2020 to January 2022 was performed using the Get With The Guidelines database. TNK bolus dose of 0.25mg/kg was used according to a network-wide policy. ICH was categorized using ECASS-3 criteria. Fisher exact test statistic was used to determine if a significant association existed between the presence of ICH and baseline ASPECTS score, endovascular treatment (EVT), and IV eptifibatide use. A benchmark less than 2% PH-2 incidence was set based on historical alteplase related PH-2 rates within our network. Social science statistics software was used for data analysis. Results: Out of 180 patients who received TNK, 25 subjects (13.89%) developed hemorrhagic transformation. Mean age was 71.88 (95% CI 65.54, 78.22). Forty-eight percent of subjects were female. Median ASPECTS score was 8 (95% CI 7.54, 8.78). Median 90 day mRS was 3 (95% CI 2.1, 3.9). Hemorrhagic transformation was classified as HI-1 in 5% (n=9), HI-2 in 1.7% (n=3), PH-1 in 3.8% (n=7), and PH-2 in 3.3% (n=6) subjects. No significant difference between subjects with other subtypes versus PH-2 was identified when adjusting for ASPECTS score >=7 versus <7 (Fisher value=1), EVT versus no EVT (Fisher value=0.65), or use of IV eptifibatide (Fisher value=0.06). Conclusion: Tenecteplase is associated with higher rates of PH-2 intracranial hemorrhage when compared with our benchmark rates of alteplase-related PH-2. This study is significantly limited by small sample size, retrospective nature, and uncontrolled variables. Larger, prospective studies are needed to validate our results.

A Double-Blinded Randomized Controlled Trial Comparing Eptifibatide Bolus Only Versus Bolus Plus Infusion In Patients Undergoing Primary Percutaneous Coronary Intervention For ST-Elevation Myocardial Infarction

BackgroundsThe use of eptifibatide combined with heparin during percutaneous coronary intervention (PCI) in patients presenting with ST-elevation myocardial infarction (STEMI) is recommended to be followed by continuous infusion. Recently, there are some suggestions that using bolus only may be sufficient and cost-effective but randomized trials are lacking. AimsThe goal of this study was to evaluate these two approaches in a double-blinded randomized control trial. MethodsThe primary PCI patients who received bolus eptifibatide were randomized to 75 mg IV eptifibatide infusion or placebo blindly. The patients were followed up for the primary outcome of vascular or bleeding complications and secondary outcome of ischemic complications. Results330 patients (165 from each group) completed the study. The mean age was 57.67 ± 11.53 years and 77.3 % were male. Major bleeding was seen in 1 patient in each group. Hematoma occurred in 8.5 %. The relative risk of hematoma and ecchymosis in bolus plus infusion group to bolus only group were 0.988 (95 % CI: 0.486–2.006) and 1.032 (95 % CI: 0.729–1.459). Multivariate analysis confirmed no significant differences in the bleeding event. Furthermore, there was no significant difference in in-hospital death or any ischemic events. (Cath lab death: 1.4 % in bolus only vs zero % in the control group, p = 0.217, stent thrombosis was seen in one patient in each group). ConclusionThere were no differences in the risk of access site ecchymosis, hematoma or major bleeding. Ischemic events and stent thrombosis rates were also similar. Our study suggests that using eptifibatide bolus only during PCI of patients with STEMI is safe and can be cost-saving.

Eptifibatide use in ischemic stroke patients undergoing endovascular thrombectomy: A matched cohort analysis.

IntroductionSmall studies have suggested that eptifibatide (EPT) may be safe in acute ischemic stroke (AIS) following intravenous thrombolysis or during endovascular therapy (EVT) for large vessel occlusion (LVO). However, studies are called upon to better delineate the safety of EPT use during EVT.MethodsA comprehensive stroke center registry (09/2015-12/2020) of consecutive adults who had undergone EVT for anterior LVO was queried. Patients treated with EPT were matched with 2 control groups based on known factors associated with intracranial hemorrhage (ICH) risk - age, Alberta Stroke Program Early Computed Tomography Score (ASPECTS), and number of thrombectomy passes. Safety outcomes (intracranial hemorrhage [ICH], parenchymal hematoma [PH-2] grade hemorrhagic transformation, symptomatic ICH [sICH]) and efficacy outcomes (TICI 2B/3 recanalization, 24-h National Institutes of Health Stroke Scale [NIHSS] score), were compared between matched groups using descriptive statistics. In addition, multivariable logistic regression was used to assess for an association between EPT and PH-1/PH-2 grade hemorrhages.ResultsA total of 162 patients were included, 54 of whom (33%) received EPT. The rate of ICH was similar between groups (p = 0.62), while PH-2 was significantly more frequent with EPT (16.7% EPT vs. 3.7 vs. 1.9%; p = 0.009), but without significant differences in sICH (5.6% EPT vs. 7.4 vs. 3.7%; p = 0.72). Rates of TICI Score ≥ 2B were nominally higher with EPT use (83.3 vs. 77.8 vs. 77.8%, p = 0.70). Between the EPT and control groups, there were no differences in 24-h NIHSS (p = 0.09) or 90-day mortality (p = 0.58). Our adjusted multivariate analysis identified that the number of passes (p < 0.01), EPT use (p < 0.01), and tandem occlusion (p = 0.03) were independent predictors of PH1/PH2 grade hemorrhage. Additionally, every unit increase in number of passes resulted in a 1.5 times greater odds of a high-grade hemorrhagic transformation in EPT-treated patients (adjusted OR = 1.594).ConclusionIn this single-center analysis, EPT use during EVT was associated with a significantly higher rate of PH1/PH2 grade hemorrhages, but not with differences in sICH, 24-h NIHSS, or 90-day mortality. Randomized prospective trials are needed to determine the safety and efficacy of EPT in this population.

Abstract WP144: Safety Of Eptifibatide Use In Ischemic Stroke Patients Undergoing Endovascular Thrombectomy: A Matched Cohort Analysis

Introduction: Small studies have suggested that eptifibatide (EPT) may be safe in acute ischemic stroke (AIS) following IV thrombolysis (tPA) or during endovascular therapy (EVT) for large vessel occlusion (LVO), however larger studies are called upon to evaluate the safety of EPT use in this setting. Methods: A stroke center registry (09/2015-12/2020) of consecutive adults who had undergone EVT for LVO was queried. Patients treated with EPT were matched with 3 control groups based on known factors associated with intracranial hemorrhage (ICH) risk - age, early infarct size (Alberta Stroke Program Computed Tomography Scale [ASPECTS] score), and number of thrombectomy passes. ICH, parenchymal hematoma (PH-2), symptomatic ICH (sICH), and 90-day modified Rankin Scale (mRS) score were compared between matched groups. Results: A total of 236 patients were included, 59 of whom (25%) received EPT. IV tPA was non-significantly more utilized in EPT patients (41%, p=0.22). Rate of any ICH was similar between groups (p=0.23), while PH-2 was significantly more frequent with EPT (21% v. 7% v. 3% v. 0%; p= 0.0001). There were no significant differences in sICH (7% EPT v. 7% v. 5% v. 2%; p=0.57), 90-day mRS (p=0.84), or 90-day mortality (p=0.92) between EPT and control groups. Conclusion: In this single center analysis, EPT during EVT was associated with a higher rate of PH-2 grade hemorrhages but not with differences in sICH, 90-day mRS, or 90-day mortality. Larger prospective studies are needed to confirm these findings.

Safety of Eptifibatide use in Thrombectomy for Treatment of Large Vessel Occlusion Stroke (5124)

Safety of Eptifibatide use in Thrombectomy for Treatment of Large Vessel Occlusion Stroke (5124)

There is no difference in safety and efficacy with Tirofiban or Eptifibatide for patients undergoing treatment of large vessel occlusion and underlying intracranial atherosclerosis

BackgroundGlycoprotein IIb/IIIa inhibitor use in acute ischemic stroke (AIS) during mechanical thrombectomy (MT) and acute stenting and angioplasty is a topic consistently debated due to concerns over safety and efficacy. Tirofiban is a glycoprotein IIb/IIIa used throughout the world now more commonly used during MT. We report the analysis of all AIS patients treated with Eptifibatide + MT vs. Tirofiban + MT. MethodsUsing a prospectively collected endovascular database at a CSC between 2013 and 2019, workflow, and outcomes were recorded. Patients are given Tirofiban, and patients given Eptifibatide were analyzed to obtain baseline demographics, modified Ranking Scale (mRS) at discharge, and 90 days follow up, pre and post thrombolysis in cerebral infarction (TICI), mortality rate, and hemorrhage rates. ResultsA total of 571 MT patients were treated: of those, 89 patients (average age 69.25 ± 14.21, 25.84% female) with underlying intracranial atherosclerosis were treated with a GpIIb/IIIa inhibitor. Analysis of 40.45% (36/89) patients treated with Tirofiban + MT and 59.55% (53/89) patients with Eptifibatide + MT was performed. There was no statistically significant difference in NIHSS upon admission (p = .441). Four patients (11.11%) in the Tirofiban + MT cohort had symptomatic hemorrhage versus four patients (7.55%) in the Eptifibatide + MT cohort (p = .564). There was no significant difference in mortality (p = .573) or final recanalization (p = .678) between the two cohorts. ConclusionTirofiban use in MT does not increase the risk of symptomatic hemorrhages or mortality compared to Eptifibatide use in MT with acute stenting. Large prospective studies are warranted to confirm the safety/efficacy of Tirofiban in acute ischemic stroke patients treated with mechanical thrombectomy and acute stenting.

Eptifibatide use following emergent carotid stenting in acute anterior circulation ischemic stroke with tandem occlusion

BackgroundEarly revascularization of the extracranial internal carotid artery in acute anterior circulation ischemic stroke (ACIS) is feasible and may improve clinical outcome. When a stent is deployed, antithrombotic agents should be administered peri-procedurally to ensure stent patency. Our institution implemented a protocol for the use of eptifibatide as a means of maintaining stent patency in the treatment of ACIS associated with cervical internal carotid artery occlusion. MethodsOur internal database was queried for patients who received emergent endovascular therapy (ET) for ACIS with stent placement and eptifibatide administration between July 2016 and 2019. ResultsTwenty nine patients met the study criteria. The etiology was large artery atherosclerosis in 26 cases. Two patients had a dissection (7%), and one had a carotid occlusion related to a recent carotid endarterectomy. Mean NIHSS was 14. Sixteen patients received IVrtPA. Extracranial-intracranial tandem occlusion (TO) was present in 21 of cases. All patients received an eptifibatide bolus followed by an infusion for approximately 24 hours post stent deployment. Head CT was obtained prior to initiation of oral dual antiplatelet therapy with aspirin and clopidogrel. Successful recanalization was achieved in all patients with no evidence of downstream embolization. Symptomatic intracerebral hemorrhage occurred in one patient. Stent occlusion occurred in two patients, only one of which was symptomatic. Favorable clinical outcome with mRS ≤ 2 at 3 months was achieved in seventeen patients. ConclusionsThe use of eptifibatide post procedure was associated with low risk of symptomatic intracranial hemorrhage, including in patients treated with rtPA.

Use of Continuous Infusions of Eptifibatide and Cangrelor in Large Vessel Occlusion Acute Ischemic Stroke After Emergent Carotid Artery Stenting

Placement of carotid stents in the setting of large vessel occlusion (LVO) is sometimes necessary in patients with steno-occlusive disease of the extracranial internal carotid artery (ICA) or ICA dissection. Use of antiplatelet agents is required to prevent in-stent thrombosis; however, after an LVO, a decompressive hemicraniectomy may be necessary. After placement of a carotid stent, a fine balance must be obtained between preventing stent-related thromboembolic complications while also maintaining the possibility of quickly and safely performing a decompressive hemicraniectomy, if indicated. In this case, we discuss the novel use of continuous eptifibatide and cangrelor infusions after carotid stent placement to maintain stent patency, while preserving the option of emergent hemicraniectomy. A 55-year-old man presented with left hemispheric ischemic symptoms due to flow failure from a left ICA dissection. He underwent emergent angiography with angioplasty and stenting of the petrous and ascending cervical segments of the left ICA. The procedure was complicated by an embolization of thrombus to a left middle cerebral artery (MCA) M2 division branch, resulting in an occlusion, which could not be opened. The patient was placed on short acting intravenous antiplatelet agents (eptifibatide infusion for 60 h and cangrelor infusion for 24 h) for prevention of in-stent thrombosis while under close observation for potential neurologic decline and need for decompressive hemicraniectomy. After 84 h of observation, the patient did not experience a decline and the antiplatelet infusions were discontinued after he received aspirin and a loading dose of clopidogrel. Intravenous eptifibatide or cangrelor infusions are short-acting antiplatelet options that can be used in patients with acute ischemic stroke from LVO in the setting of ICA stent placement when there exists a potential for decompressive hemicraniectomy. J Neurol Res. 2020;10(3):99-103 doi: https://doi.org/10.14740/jnr591

Use of Continuous Infusions of Eptifibatide and Cangrelor in Large Vessel Occlusion Acute Ischemic Stroke After Emergent Carotid Artery Stenting

Placement of carotid stents in the setting of large vessel occlusion (LVO) is sometimes necessary in patients with steno-occlusive disease of the extracranial internal carotid artery (ICA) or ICA dissection. Use of antiplatelet agents is required to prevent in-stent thrombosis; however, after an LVO, a decompressive hemicraniectomy may be necessary. After placement of a carotid stent, a fine balance must be obtained between preventing stent-related thromboembolic complications while also maintaining the possibility of quickly and safely performing a decompressive hemicraniectomy, if indicated. In this case, we discuss the novel use of continuous eptifibatide and cangrelor infusions after carotid stent placement to maintain stent patency, while preserving the option of emergent hemicraniectomy. A 55-year-old man presented with left hemispheric ischemic symptoms due to flow failure from a left ICA dissection. He underwent emergent angiography with angioplasty and stenting of the petrous and ascending cervical segments of the left ICA. The procedure was complicated by an embolization of thrombus to a left middle cerebral artery (MCA) M2 division branch, resulting in an occlusion, which could not be opened. The patient was placed on short acting intravenous antiplatelet agents (eptifibatide infusion for 60 h and cangrelor infusion for 24 h) for prevention of in-stent thrombosis while under close observation for potential neurologic decline and need for decompressive hemicraniectomy. After 84 h of observation, the patient did not experience a decline and the antiplatelet infusions were discontinued after he received aspirin and a loading dose of clopidogrel. Intravenous eptifibatide or cangrelor infusions are short-acting antiplatelet options that can be used in patients with acute ischemic stroke from LVO in the setting of ICA stent placement when there exists a potential for decompressive hemicraniectomy. J Neurol Res. 2020;10(3):99-103 doi: https://doi.org/10.14740/jnr591

Contemporary Use of Glycoprotein IIb/IIIa Inhibitors in Patients with Left Ventricular Assist Devices

Purpose The efficacy of glycoprotein IIB/IIIA inhibitor (IIB/IIA) use in patients who receive left ventricular assist devices (LVAD) has not been well studied. A prior single center study of eptifibatide use for pump thrombosis in almost exclusively HeartMate II (HMII) LVAD patients concluded that the risks of such use outweighed the benefits. We sought to analyze the outcomes of IIB/IIIA use in our more contemporary cohort of mixed axial and centrifugal flow LVAD patients. Methods We performed a retrospective analysis of all patients with LVADs implanted at Stanford Hospital from 2010-2018. We used the electronic medical record to identify LVAD patients who received IIB/IIIA inhibitors for suspected pump thrombus. Outcomes assessed included resolution of thrombus, need for pump exchange, and adverse events such as stroke and death. Results Out of 304 patients who had an LVAD placed during the study period, 42 (14%) received IIB/IIIA inhibitors after LVAD placement. Of this subset, 74% were male, 69% received HM II LVADs (31% HeartWare), 71% were implanted as destination therapy, and 88% received eptifibatide (12% tirofiban). The average time from implant to IIB/IIIA use was 278 days (SD 365). 50% of patients had clinical resolution of their thrombus (80% tirofiban, 46% eptifibatide, p = 0.14). 29% of patients suffered a stroke, all of whom were exposed to eptifibatide (0% tirofiban vs 32% eptifibatide, p = 0.15). 43% of patients went on to eventual cardiac transplantation, 45% required pump exchange (0% tirofiban, 51% epitifibatide, p = 0.02), and 19% died in total from thrombotic complications, including pump exchange. There were no significant differences in the rate of stroke, pump exchange, or death with IIB/IIIA use when stratified by type of LVAD (HMII vs HeartWare). Conclusion IIB/IIIA inhibitors can be effective in treating suspected LVAD pump thrombus, with resolution of thrombus in half of cases in our experience. Whether outcomes differ based on the type of IIB/IIIA inhibitor used requires further investigation. The high proportion of patients who died or required pump exchange/eventual transplantation suggests that the use of IIB/IIIA inhibitors carries risk, and the effect may not be durable. Identification of patients and clinical scenarios that minimize risk and improve efficacy of IIB/IIA use is paramount.

Comparison of In-Hospital Bleeding and Cardiovascular Events with High-Dose Bolus Tirofiban and Shortened Infusion to Short-Duration Eptifibatide as Adjunctive Therapy for Percutaneous Coronary Intervention

Potent platelet inhibition is one of the most important medical interventions to prevent ischemic complications during and after percutaneous coronary intervention (PCI). Practice has evolved with the introduction of potent oral P2Y12 inhibitors that provide quick, effective platelet inhibition, and the need for routine glycoprotein IIb/IIIa inhibitors (GPIs) has decreased. Additionally, a shorter duration of GPI infusion has been shown to be safe with adequate oral antiplatelet loading, but clinical outcome data are limited to eptifibatide. This single-center, retrospective cohort study analyzed in-hospital outcomes for patients who received adjunctive GPI therapy for PCI before and after an institution-wide switch to high-dose bolus tirofiban with shortened infusion from short-duration eptifibatide. The primary end point was a composite in-hospital outcome of major and minor bleeding and cardiovascular events (death, myocardial infarction, coronary artery bypass grafting, ischemic stroke, and target vessel revascularization). Secondary end points included bleeding and cardiovascular event types. A total of 357 and 446 patients received eptifibatide and tirofiban, respectively, from February 1, 2014 through September 30, 2017. Thirty five eptifibatide and 46 tirofiban patients experienced an in-hospital composite event (9.8% vs 10.3%, p = 0.81). There was no difference found between in-hospital bleeding (6.4% vs 5.4%, p = 0.52) or cardiovascular events (5.6% vs 6.5%, p = 0.60) with the use of eptifibatide or tirofiban, respectively. Multivariable analysis showed that patients with transradial access or an indication of unstable angina were less likely to experience an in-hospital composite event (OR 0.30 and 0.19, respectively, p <0.001 for both). In conclusion, the use of high-dose bolus tirofiban with shortened infusion versus short-duration eptifibatide was not associated with an increase of in-hospital bleeding or cardiovascular events.

The Use of Eptifibatide Alone or in Combination With Heparin or Argatroban for Suspected Thrombosis in Patients With Left Ventricular Assist Devices.

Pump thrombosis and hemolysis in patients with left ventricular assist devices (LVADs) are associated with significant morbidity and mortality. Intensification of anticoagulation has been suggested as potential therapy, with mixed results. The aim of this study is to assess the safety and efficacy of adding eptifibatide with or without an anticoagulation agent in managing patients with LVAD presenting with hemolysis and suspected pump thrombosis. This retrospective single center study included all patients who presented with their first episode of suspected pump thrombosis and were treated with eptifibatide with or without an anticoagulant between March 1, 2011 and July 30, 2015. A total of 27 patients (23 HeartMate II, 4 HeartWare) were identified. The average age was 55 years (range 19-75) and time from implant to event averaged 513 days (range 35-1760). The average lactate dehydrogenase on presentation was 1111 and 63% of patients had power elevations. The average international normalized ratio (INR) on admission was 2.4, with INR of ≥2 in 21/27 patients. All patients received eptifibatide: 10 received eptifibatide only, 9 received eptifibatide and argatroban, and 8 received eptifibatide and heparin. Warfarin was continued in 25/27 patients. Overall, 21 patients (77.8%) were successfully treated medically, 5 (18.5%) underwent pump exchange, and 1 (3.7%) died. There were no differences in outcomes or complications between the three treatment groups. Despite initial success, 12/21 patients developed repeat episodes of hemolysis at 1 year. The 1-year survival in the patients treated medically was 90% and surgically was 60%. Our experience indicates that medical therapy for hemolysis and suspected LVAD thrombosis with warfarin and eptifibatide alone or in combination with argatroban or heparin appears safe and may be effective, although the episodes of recurrent hemolysis after medical management remain high.

Ischemic Stroke After Treatment of Intraprocedural Thrombosis During Stent-Assisted Coiling and Flow Diversion.

Intraprocedural thrombosis poses a formidable challenge during neuroendovascular procedures because the risks of aggressive thromboembolic treatment must be balanced against the risk of postprocedural hemorrhage. The aim of this study was to identify predictors of ischemic stroke after intraprocedural thrombosis after stent-assisted coiling and pipeline embolization device placement. A retrospective analysis of intracranial aneurysms treated with stent-assisted coiling or pipeline embolization device placement between 2007 and 2016 at 4 major academic institutions was performed to identify procedures that were complicated by intraprocedural thrombosis. Intraprocedural thrombosis occurred in 34 (4.6%) procedures. Postprocedural ischemic stroke and hemorrhage occurred in 20.6% (7/34) and 11.8% (4/34) of procedures complicated by intraprocedural thrombosis, respectively. Current smoking was an independent predictor of ischemic stroke. There was no statistically significant difference in the rate of ischemic stroke or postprocedural hemorrhage with the use of abciximab compared with the use of eptifibatide in treatment of intraprocedural thrombosis. Current protocols for treatment of intraprocedural thrombosis associated with placement of intra-arterial devices were effective in preventing ischemic stroke in ≈80% of cases. Current smoking was the only independent predictor of ischemic stroke.

Intracoronary Eptifibatide During Primary Percutaneous Coronary Intervention in Early Versus Late Presenters with ST Segment Elevation Myocardial Infarction: A Randomized Trial.

IntroductionThe role of intracoronary (IC) eptifibatide in primary percutaneous coronary intervention (PPCI) for ST segment elevation myocardial infarction (STEMI) and whether time of patient presentation affects this role are unclear. We sought to evaluate the benefit of IC eptifibatide use during primary PCI in early STEMI presenters compared to late STEMI presenters.MethodsWe included 70 patients who presented with STEMI and were eligible for PPCI. On the basis of symptom-to-door time, patients were classified into two arms: early (<3 h, n = 34) vs late (≥3 h, n = 36) presenters. They were then randomized to local IC eptifibatide infusion vs standard care (control group). The primary end point was post-PCI myocardial blush grade (MBG) in the culprit vessel. Other end points included corrected TIMI frame count (cTFC), ST segment resolution (STR) ≥70%, and peak CKMB.ResultsIn the early presenters arm, no difference was observed in MBG results ≥2 in the IC eptifibatide and control groups (100% vs 82%; p = 0.23). In the late presenters arm, the eptifibatide subgroup was associated with improved MBG ≥2 (100% vs 50%; p = 0.001). IC eptifibatide in both early and late presenters was associated with less cTFC (early presenters 19 vs. 25.6, p = 0.001; late presenters 20 vs. 31.5, p < 0.001) and less peak CKMB (early presenters 210 vs 260 IU/L, p = 0.006; late presenters 228 vs 318 IU/L, p = 0.005) compared with the control group. No difference existed between both groups in STR index in early and late presenters.ConclusionIC eptifibatide might improve the reperfusion markers during PPCI for STEMI patients presenting after 3 h from onset of symptoms. A large randomized study is recommended to ascertain the benefits of IC eptifibatide in late presenters on clinical outcomes.

Use of Contraindicated Antiplatelet Medications in the Setting of Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.

Several antiplatelet medications used during and after percutaneous coronary intervention (PCI) are contraindicated for specific patient groups. A broad assessment of contraindicated medication use and associated clinical outcomes is not well described. Using national Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data for all PCI between 2007 and 2013, we evaluated patients with contraindications to commonly used antiplatelet medications during and after PCI, defined in accordance with package inserts. Adjusted association between contraindicated medication use and outcomes of periprocedural bleeding and 30-day mortality were assessed using Cox proportional hazards with inverse probability weighting. Among 64 294 patients undergoing PCI, 11 315(17.6%) had a contraindication to a common antiplatelet medication and 737 (6.5%) of these patients received a contraindicated medication. In unadjusted analyses, any contraindicated medication use was associated with both increased bleeding and 30-day mortality. In adjusted models, contraindicated abciximab use in patients with thrombocytopenia (hazard ratio, 2.23; 95% confidence interval, 1.58-3.16) and in patients with a previous stroke (hazard ratio, 1.93; 95% confidence interval, 1.37-2.71) remained significantly associated with increased bleeding. Contraindicated abciximab use was not significantly associated with 30-day mortality in adjusted models. Use of eptifibatide in dialysis patients was not significantly associated with an increased risk of bleeding or mortality. In this national cohort, ≈18% of patients undergoing PCI had contraindications to common antiplatelet medications. Approximately 6% of those patients received a contraindicated medication with attendant bleeding risk, although this did not translate into significantly higher risk of 30-day mortality. Continued efforts to reduce contraindicated medication use may help avoid periprocedural complications.

Abstract TP88: Phase I Experience of Safety of Eptifibatide in Select Patients With Elective Cerebral Aneurysm Embolization

Background: Literature has reported the application of oral Aspirin and/or Clopidogrel in significantly reducing thromboembolic complications after aneurysmal coiling. There is a lack of data on intravenous Eptifibatide use as the choice of antiplatelet agent in the setting of elective cerebral aneurysmal embolization. Previously we reported on safety outcomes on 19 patients that received intravenous Eptifibatide while undergoing elective embolization of cerebral aneurysms. We now report on more patients to further assess safety outcome with the aim of further corroborating our previous findings. Methods: Of all the patients that underwent elective cerebral aneurysmal embolization from 2010-2015 at our university affiliated comprehensive stroke center, patients that received Eptifibatide after aneurysmal embolization were reviewed. Eptifibatide was administered intra-arterially as a 135-μg/kg single-dose bolus, and then continued on intravenous infusion of 0.5-μg/kg/min post-procedurally. Inclusion criteria included clinically assessed risk of clot formation or propagation based on angiographic characteristics. Charts were reviewed for all patients to assess for medical/procedural complications including symptomatic and asymptomatic hemorrhages, groin hematoma, epistaxis and gross hematuria. Results: A total of 30 patients (mean age 61, 22% male [n=7]) received Eptifibatide for a mean duration of 19 hours (range 4-29 hours). The aneurysmal size ranged from 2.4 to 23 mm and 83% [n=25] were located in anterior circulation. None of the patients demonstrated symptomatic/asymptomatic hemorrhage. One patient had a groin hematoma without need of transfusion. Conclusion: IV Eptifibatide may represent another safe option for rapid and reversible antiplatelet therapy for reduction of thromboembolic complication associated with aneurysmal embolization in select patient population.

Abstract 390: Use of Eptifibatide in patients with ventricular assist devices and Bleeding outcomes

Background: Pump thrombosis is a dreaded complication in patients with left ventricular assist devices (LVADs). Intravenous anticoagulation is often instituted prior to surgical pump exchange. The use of eptifibatide, a glycoprotein IIb/IIIa inhibitor has been reported with data showing increased adverse events by as much as 65%. This study evaluated eptifibatide use for suspected pump thrombus/thrombosis and bleeding outcomes Methods: This was a single center retrospective study of eptifibatide use in patients with suspected pump thrombus. All LVAD patients who received eptifibatide for suspected pump thrombus from October 22, 2011, through April 19, 2014 were included. Pump thrombosis was suspected if one or more was present: elevated lactate dehydrogenase, decreased haptoglobin, elevated free plasma hemoglobin and persistently elevated powers. The study was approved by the institutional board review. Results: A total of 17 patients (13 Heart Mate II, 3 Heart Ware and 1 Abiomed AB5000 LVAD) with 25 admission events received eptifibatide (dose range, 0.25-2 μg/kg/min). The mean time from device implantation to eptifibatide therapy was 660 days (range: 1 - 1809 days). 9 (36%) patients underwent pump exchange while the rest resolved medically. 7 (28%) patients had confirmed Pump/LVAD thrombus while 3 (12%) had major bleeding events (1-GI, 1-Oral and 1-Acute Intracranial Hemorrhage) requiring drug interruption. 8(47%) patients had combined 11 minor mucosal bleeding events (Oral-2, GU-5, GI-1 and Nasal-3) that did not require therapy interruption. 2 of the 3 (67%) patients with major bleeding died as a result. Conclusions: Minor bleeding is more common than major bleeding with eptifibatide use in patients with suspected pump thrombus. Comparative effectiveness studies of eptifibatide therapy in suspected pump thrombosis are needed to assess risk benefit ratio.