Glycoprotein IIb/IIIa Inhibitors Research Articles

Mechanical Thrombectomy of Acutely Occluded Flow-Diverters - Neuroendovascular Surgical Technique Demonstration: 2-Dimensional Operative Video.

Flow-diversion with pipeline embolization devices (PED, Medtronic, Dublin, Ireland) is widely used for embolization of complex intracranial aneurysms.1 In-stent thrombosis can be a dreadful complication after PED deployment. Intra-arterial glycoprotein IIb-IIIa inhibitors and intravenous tissue plasminogen activator have been used in an attempt to achieve recanalization.2 However, large clots may not be effectively dissolved by pharmacological agents, thus requiring mechanical thrombectomy (MT).3 Our group recently published the first technical report on successful MT of acutely occluded PEDs in 2 patients.4 Here, we showcase the successful MT of a patient who sustained acute in-stent PED thrombosis. Informed written consent was obtained. In this case, we combined stentriever and contact aspiration thrombectomy techniques. We highlight important pitfalls and tips to prevent PED displacement, removal or vessel injury during endovascular manipulation. The most important consideration is to deploy the distal end of the stentriever inside the PED but also as distally as possible. Thus, correct apposition and alignment of the distal markers of both devices is performed under "native" unsubstracted fluoroscopic view (for better PED visualization) before MT. In this surgical video we describe the technique in detail.

Intra-Arterial Glycoprotein IIb/IIIa Inhibitor Treatment for Symptomatic Intracranial Atherosclerotic Stenosis Presenting as Large Vessel Occlusions.

IntroductionThere is no consensus on the optimal treatment for acute ischemic stroke (AIS) large vessel occlusions (LVOs) or near-occlusions with underlying intracranial atherosclerotic stenosis (ICAS). We report the first American series using intra-arterial (IA) glycoprotein IIb/IIIa inhibitors (GPIs) as a stand-alone revascularization technique for ICAS presenting with large vessel ischemic syndromes.MethodsRecords at two centers of 140 patients presenting with AIS undergoing stroke intervention from January 2017 to June 2019 were retrospectively reviewed. Patients treated with IA GPIs were identified, and baseline factors, imaging, procedural characteristics, hospital course, and outcomes were collected. Six patients with ICAS underlying their acute symptomatic near occlusion or LVO were treated with IA GPI. Four near-occlusions were treated with IA GPI as the first-line therapy, while two LVOs were treated with IA GPI as an adjunct therapy to thrombectomy.ResultsThe mean age was 61.3 years (range 36-79), presentation National Institute of Health Stroke Scale (NIHSS) was 10 (4-18), time from last seen well to treatment was 434.5 minutes (164-1290), and time from groin puncture to revascularization was 67.3 minutes (26-94). Three patients received intravenous (IV) tissue plasminogen activator (tPA), and all patients received an IA weight-based GPI infusion. Five patients had thrombolysis in cerebral ischemia (TICI) 3, and one patient had TICI 2b. The mean discharge NIHSS was 2.5 (0-8). The mean modified Rankin scale was 1.3 (range 0-4) at discharge and .8 at three months. No patients had a postprocedural symptomatic hemorrhage.ConclusionOur results highlight the utility of IA GPI administration as the first-line therapy for symptomatic ICAS near occlusions or as a rescue technique after failed thrombectomy for LVO patients suspected of underlying ICAS.

Safety and Efficacy of Glycoprotein IIb/IIIa Inhibitors in Patients With Acute Myocardial Infarction in the Presence of Intracoronary Thrombus: An Analysis From the Grand Drug-eluting Stent Registry

PurposeTo evaluate the safety and efficacy of glycoprotein IIb/IIIa inhibitors (GPIs) in patients with acute myocardial infarction (AMI) in the presence of intracoronary thrombus undergoing percutaneous coronary interventions. MethodsThis study, performed from January 1, 2004, to November 31, 2014, at 55 centers in Korea, was based on the Grand Drug-Eluting Stent registry, which is a Korean, nationwide, multicenter, pooled registry of drug-eluting stents. The registry enrolled all-comers without any exclusion criteria except patient withdrawal of consent. A total of 1329 patients with AMI who had an overt intracoronary thrombus at the initial coronary angiography were analyzed. The efficacy end point was a 1-year major adverse cardiovascular event, defined as a composite of all death, myocardial infarction, target lesion revascularization, and stent thrombosis. The primary safety end point was any 30-day bleeding event. FindingsGPIs were associated with a significantly higher rate of any bleeding events at 30 days (0.9% vs 2.9% in the non-GPI and GPI groups, respectively; P = 0.015), whereas GPI use was the only significant independent predictor of 30-day bleeding events by multivariable Cox proportional hazards regression analysis (hazard ratio = 4.76; 95% CI, 1.66–13.64; P = 0.004). Regarding the efficacy end points, no significant differences were noted according to GPI use (7.0% vs 9.0%, P = 0.287), and GPI use has no significant effect on 1-year major adverse cardiovascular events (hazard ratio = 1.33; 95% CI, 0.82–2.15; P = 0.253). ImplicationsEarly upstream use of GPIs should not be considered even in the presence of an intracoronary thrombotic occlusion. ClinicalTrials.gov identifier: NCT03507205.

Antithrombotic regimens for percutaneous coronary intervention of the left main coronary artery: The EXCEL trial.

We compared the effect of bivalirudin or heparin and use or nonuse of glycoprotein IIb/IIIa inhibitors (GPI) on the outcome of left main coronary artery (LMCA) percutaneous coronary intervention (PCI) in the randomized EXCEL trial. The optimal antithrombotic regimen to support PCI of the LMCA remains controversial because of low representation of this subset in clinical trials. The PCI cohort (n = 928) in EXCEL was divided according to bivalirudin versus heparin antithrombin treatment and compared for the primary composite endpoint of death, myocardial infarction (MI), or stroke at 30 days and 5 years. Bivalirudin was used in 319 patients (34.4%). The composite endpoint at 30 days occurred in 7.2% versus 3.8% bivalirudin and heparin patients, respectively, p = .02; at 5 years, the composite endpoint occurred in 26.3% versus 19.9% bivalirudin and heparin patients, respectively, p = .02. Major bleeding was more frequent in bivalirudin patients (4.1% versus 1.3%, p = .008). There were no differences in stent thrombosis between the groups. Bivalirudin use was an independent predictor of the 30-day composite endpoint (OR 2.88, 95% CI 1.28-6.48, p = .01) but not of the 5-year composite endpoint (OR 1.30, 95% CI 0.84-2.02, p = .23). GPI use was infrequent (n = 67, 7.2%) and was not associated with adverse outcomes. Among patients undergoing LMCA PCI in the EXCEL trial, procedural use of bivalirudin was associated with greater rates of periprocedural MI and the 30-day composite endpoint without reducing bleeding complications. Five-year outcomes were similar. GPIs were used infrequently and were not associated with clinical outcomes.

Bivalirudin Versus Heparin During Intervention in Acute Coronary Syndrome: A Systematic Review of Randomized Trials.

Introduction: Bivalirudin and heparin are the two most commonly used anticoagulants used during Percutaneous Coronary Intervention (PCI). The results of Randomized Controlled Trials (RCTs) comparing bivalirudin versus heparin monotherapy in the era of radial access are controversial, questioning the positive impact of bivalirudin on bleeding. The purpose of this systematic review is to summarize the results of RCTs comparing the efficacy and safety of bivalirudin versus heparin with or without Glycoprotein IIb/IIIa Inhibitors (GPI).Methods:This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA statements for reporting systematic reviews. We searched the National Library of Medicine PubMed, Clinicaltrial.gov and the Cochrane Central Register of Controlled Trials to include clinical studies comparing bivalirudin with heparin in patients undergoing PCI. Sixteen studies met inclusion criteria and were reviewed for the summary.Findings: Several RCTs and meta-analyses have demonstrated the superiority of bivalirudin over heparin plus routine GPI use in terms of preventing bleeding complications but at the expense of increased risk of ischemic complications such as stent thrombosis. The hypothesis of post- PCI bivalirudin infusion to mitigate the risk of acute stent thrombosis has been tested in various RCTs with conflicting results. In comparison, heparin offers the advantage of having a reversible agent, of lower cost and reduced incidence of ischemic complications.Conclusion:Bivalirudin demonstrates its superiority over heparin plus GPI with better clinical outcomes in terms of less bleeding complications, thus making it as anticoagulation of choice particularly in patients at high risk of bleeding. Further studies are warranted for head to head comparison of bivalirudin to heparin monotherapy to establish an optimal heparin dosing regimen and post-PCI bivalirudin infusion to affirm its beneficial effect in reducing acute stent thrombosis.

Safety of Glycoprotein IIb-IIIa Inhibitors Used in Stroke-Related Treatment: A Systematic Review and Meta-Analysis.

Background:Endovascular therapy and intravenous thrombolysis with recombinant tissue plasminogen activator are the 2 most recommended treatments for acute ischemic stroke (AIS). Glycoprotein (GP) IIb-IIIa inhibitors are short-acting selective reversible antiplatelet agents that emerged as promising therapeutic agents for AIS about 10 years ago. Given the unclear safety profile and application coverage of GP inhibitors, we conducted this meta-analysis to explore the same.Methods:We used GP IIb-IIIa inhibitors, intracranial hemorrhage, and mortality as the key words on Medline, Web of Science, and the Embase databases. Randomized controlled trials, prospective literatures, and retrospective studies in English published between 1990 and 2020 were screened. The outcomes were relative risk (RR) of death and 90-day intracerebral hemorrhage (ICH). We pooled the results in 2 categories and conducted a subgroup analysis stratified by different drugs. The choice of the effects model depended on the value of I 2.Results:In all, 3700 patients from 20 studies were included. No GP IIb-IIIa inhibitors were found to have a remarkable influence on the ICH rate. The RR values of symptomatic ICH for abciximab and eptifibatide were 4.26 (1.89, 9.59) and 0.17 (0.04, 0.69), respectively. Both tirofiban and abciximab could decrease the mortality rate within 90 days. Age > 70 years, National Institutes of Health Stroke Scale > 15, and overall dose > 10 mg are risk factors for ICH events with tirofiban usage. Thrombectomy combined with tirofiban was safe for arterial reocclusion prevention.Conclusions:In stroke-related treatment, administration of GP IIb-IIIa inhibitors could be safe, but care should be taken regarding drug species and doses. Abciximab can increase the risk of symptomatic intracranial hemorrhage. Tirofiban and eptifibatide can be considered safe in low doses. Suitable patients should be selected using strict criteria.

Safety and efficacy of bivalirudin monotherapy in patients with non-ST-segment elevation acute coronary syndromes with positive biomarkers undergoing percutaneous coronary intervention: a report from the Acute Catheterization and Urgent Intervention Triage Strategy trial

There are limited data on bivalirudin monotherapy in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) with positive biomarkers of myocardial necrosis (troponin and/or creatine kinase-myocardial band isoenzyme). We sought to evaluate the safety and efficacy of bivalirudin monotherapy in patients with positive biomarkers from the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. We compared the net adverse clinical events [composite ischemia - (death, myocardial infarction, or unplanned ischemic revascularization) - or noncoronary artery bypass graft surgery (CABG)-related major bleeding] among patients with biomarker-positive NSTE-ACS in the ACUITY trial overall and by antithrombotic strategy. Among 13 819 patients with NSTE-ACS enrolled in ACUITY, 4728 patients presented with positive biomarkers and underwent an early invasive strategy. Of those, 1547 were randomized to heparin plus a glycoprotein IIb/IIIa inhibitor (GPI), 1555 to bivalirudin plus GPI, and 1626 to bivalirudin monotherapy. Compared with biomarker-negative patients, biomarker-positive patients had higher 30-day rates of net adverse clinical events (14.0 vs. 12.4%; P = 0.04), all-cause death (1.3 vs. 0.5%; P = 0.001), cardiac death (1.1 vs. 0.5%; P = 0.005), and non-CABG-related major bleeding (6.5 vs. 5.2%, P = 0.03). At 30 days, bivalirudin monotherapy was associated with significantly less non-CABG-related major bleeding (bivalirudin monotherapy 4.1% vs. bivalirudin plus GPI 8.4% vs. heparin plus GPI 7.1%) with comparable rates of composite ischemia (bivalirudin monotherapy 9.2% vs. bivalirudin plus GPI 9.9% vs. heparin plus GPI 8.4%). In a multivariable model, bivalirudin monotherapy was associated with a significant reduction in non-CABG-related major bleeding but was not associated with an increased risk of death, myocardial infarction, unplanned revascularization or stent thrombosis. Compared with heparin plus GPI or bivalirudin plus GPI, bivalirudin monotherapy provides similar protection from ischemic events with less major bleeding at 30 days among patients with NSTE-ACS and positive biomarkers.

901 Thrombocytopenia Risk Following Glycoprotein IIB/IIIA Inhibitor use for ST-Elevation Myocardial Infarction (STEMI)

The role of glycoprotein IIB/IIIA Inhibitor (GPI) use during ST-elevation myocardial infarction (STEMI) is uncertain in the era of contemporary P2Y12 inhibitors. They can be helpful in selected patients but requires careful consideration of potential risks including increased thrombocytopenia and propensity to major bleeding events. We performed a multicentered, retrospective, cohort study of consecutive patients presenting with STEMI, who underwent either primary percutaneous intervention (pPCI) or thrombolysis with subsequent coronary angiogram. Select patients were administered GPI according to best practice guidelines. Platelet values were sourced from all STEMI admissions between 2014–2019 at baseline, 24 and 48 hours post angiogram. Secondary analysis examined major bleeding events up to 1 month. 420 patients were analysed with 25 administered GPI (10 Tirofiban, 15 Abciximab). At 48 hours, there was a non-significant average decrease in platelets of 45.1x109/L compared to 19.9x109/L in the pPCI group (p=0.056) and an average decrease of 66.1x109/L compared to 18.3x109/L in the thrombolysis group (p=0.59) in those that did and did not receive GPI respectively. Furthermore, there was no significant difference in major bleeding between the two groups (2.5% GPI group, 2.8% in non GPI). There was no statistically significant difference in platelet reduction with GPI use during coronary angiogram and their use did not equate to any increase in detectable major bleeding at one month. Our findings suggest that GIIB/IIIA-I use should not be limited due to bleeding concerns in the STEMI population, although the GPI population size was small.

One-Year clinical outcomes of drug-eluting stents versus bare-metal stents in large coronary arteries

Background: Drug-eluting stents (DESs) have been shown to reduce the risk of restenosis and other adverse cardiac events after percutaneous coronary intervention (PCI) as compared with bare-metal stents (BMSs). However, the superiority of DES over BMS has been questioned in large vessels. We evaluated the risks and benefits of the use of DES versus BMS in patients who undergo stenting of large coronary arteries (≥3.5 mm) up to 1-year follow-up. Materials and Methods: This was a prospective study carried out in all-comer patients enrolled between January 2015 and December 2015. The patients with the variable indication for PCI, multivessel involvement, prior revascularization, and adjuvant drugs such as GP IIb–IIIa inhibitors were included in the study. However, patients who did not provide written informed consent and received both DES and BMS were excluded from the study. The clinical outcomes were evaluated at 1 year. Results: A total of 266 lesions (240 patients) in the large coronary arteries were stented, of which 130 lesions were treated with BMS and 136 lesions were treated with DES. At 1-year follow-up, target lesion revascularization/target vessel revascularization (P = 0.6492) and all-cause death (P = 0.7098) did not differ significantly between the two groups. In addition, no significant difference was found in patients requiring medical management (P = 0.3937) as well as number of asymptomatic patients (P = 0.2027). Conclusions: At 1-year follow-up, BMSs and DESs showed similar clinical outcomes in large coronary arteries. Hence, the use of BMS in large coronary arteries (≥3.5 mm) should not be discouraged unless clinically indicated.

A young patient with acute myocardial infarction due to Bonsai treated with glycoprotein IIbIIIa inhibitor

A young patient with acute myocardial infarction due to Bonsai treated with glycoprotein IIbIIIa inhibitor

Antiplatelet Therapy in Flow Diversion.

Dual antiplatelet therapy is typically employed as a means to mitigate thromboembolic complications after deployment of flow diverters, most commonly consisting of aspirin with either clopidogrel, prasugrel, or ticagrelor. Recent studies have demonstrated at least similar efficacy for ticagrelor as compared to clopidogrel in the form of periprocedural complications and angiographic results. Though controversial, systematic reviews of platelet function assay usage have demonstrated greater rates of thrombotic complications in antiplatelet hyporesponders and greater rates of hemorrhagic complications in hyperresponders. Though in its infancy, the management of antiplatelet therapy for acutely ruptured aneurysms treated with flow diversion is not yet standardized, with approaches including intravenous glycoprotein IIb-IIIa inhibitors and subsequent antiplatelet loading vs antiplatelet loading, response assessment, and subsequent treatment.

Trends of Use and Outcomes Associated With Glycoprotein-IIb/IIIa Inhibitors in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention.

Background: Glycoprotein IIb/IIIa inhibitors (GPIs) are a treatment option in the management of acute coronary syndromes (ACSs). Evidence supporting the use of GPIs predates trials establishing the benefits of P2Y12 inhibitors, routine early invasive therapy, and thrombectomy devices in patients with ACS. Objective: The aim of this study was to determine trends in GPI use and their associated outcomes in contemporary practice. Methods: We assessed GPI use in patients with ACS undergoing percutaneous coronary intervention (PCI) from the Melbourne Interventional Group registry (2005-2013). The primary endpoint was the 30-day incidence of major adverse cardiovascular events (MACE). The safety endpoint was in-hospital major bleeding. Results: GPIs were used in 40.5% of 12 357 patients with ACS undergoing PCI. GPI use decreased over the study period (P for trend <0.0001). Patients were more likely to receive GPIs if they were younger, presented with a ST-elevation myocardial infarction (STEMI), had more complex (B2/C-type) lesions, and when thrombectomy devices were used (all P < 0.0001). MACE were higher in patients receiving GPI (4.9% vs 4.1%, P = 0.03). Propensity score matching revealed no difference in 30-day mortality and 30-day MACE (odds ratio [OR] = 1.00; 95% CI = 0.99-1.004 and OR = 1.01; 95% CI = 0.99-1.02, respectively). GPI use was associated with more bleeding complications (3.6% vs 1.8%, P < 0.0001). Conclusion and Relevance: GPI use in ACS patients undergoing PCI has declined, and use appears to be dictated by ACS type and lesion complexity, as opposed to high-risk comorbidities. GPI use was associated with a doubling in bleeding complications.

Efficacy and Safety of Glycoprotein IIb/IIIa Inhibitors on Top of Ticagrelor in STEMI: A Subanalysis of the ATLANTIC Trial.

Glycoprotein IIb/IIIa inhibitors (GPIs) in combination with clopidogrel improve clinical outcome in ST-elevation myocardial infarction (STEMI); however, finding a balance that minimizes both thrombotic and bleeding risk remains fundamental. The efficacy and safety of GPI in addition to ticagrelor, a more potent P2Y12-inhibitor, have not been fully investigated. 1,630 STEMI patients who underwent primary percutaneous coronary intervention (PCI) were analyzed in this subanalysis of the ATLANTIC trial. Patients were divided in three groups: no GPI, GPI administration routinely before primary PCI, and GPI administration in bailout situations. The primary efficacy outcome was a composite of death, myocardial infarction, urgent target revascularization, and definite stent thrombosis at 30 days. The safety outcome was non-coronary artery bypass graft (CABG)-related PLATO major bleeding at 30 days. Compared with no GPI (n = 930), routine GPI (n = 525) or bailout GPI (n = 175) was not associated with an improved primary efficacy outcome (4.2% no GPI vs. 4.0% routine GPI vs. 6.9% bailout GPI; p = 0.58). After multivariate analysis, the use of GPI in bailout situations was associated with a higher incidence of non-CABG-related bleeding compared with no GPI (odds ratio [OR] 2.96, 95% confidence interval [CI] 1.32-6.64; p = 0.03). However, routine GPI use compared with no GPI was not associated with a significant increase in bleeding (OR 1.78, 95% CI 0.88-3.61; p = 0.92). Use of GPIs in addition to ticagrelor in STEMI patients was not associated with an improvement in 30-day ischemic outcome. A significant increase in 30-day non-CABG-related PLATO major bleeding was seen in patients who received GPIs in a bailout situation.

The Feasibility and Safety of Same-Day Discharge for All Comers after Elective Percutaneous Coronary Interventions

BackgroundThe safety of same day discharge (SDD) after percutaneous coronary interventions (PCI) has been demonstrated in several studies. However, SDD was only allowed in patients meeting strict criteria. We aimed to evaluate the feasibility and safety of SDD following elective-PCI in all comers. MethodsIn 2012, we implemented a strategy of SDD for all elective PCI (no exclusion) but admissions were allowed at the discretion of the treating physician. We assessed the feasibility and safety of this approach in consecutive patients who underwent elective PCI at WVU. ResultsOut of 3355 patients who underwent PCI between 2012 and 2016, 691 (21%) presented electively. Radial access was utilized in 480 (69.5%). Same day discharge was achieved in 539/691 (78%), and there was no difference between patients who had SDD and those who were admitted with regards to the 30-day major adverse cardiovascular and cerebrovascular events (3.2% vs. 3.5% respectively, P = 0.195). Predictors of SDD failure were procedural complications (OR 12.08, 95%CI 2.20–57.8. P = 0.002), use of Glycoprotein IIB-IIIA inhibitors (OR 3.45, 95%CI 1.067–11.41, P = 0.039), femoral access (OR 2.067, 95%CI 1.25–3.419, p = 0.005), anemia (OR 1.80, 95%CI 1.06–3.04, P = 0.029), home distance ≥60 miles (OR 1.68, 95%CI 1.03–2.72, P = 0.037). ConclusionSDD is feasible in the majority of all-comers after elective PCI, and is not associated with increase in adverse events at 30-days. Certain procedural and patient's characteristics predict SDD failure. If validated in prospective studies, these factors can possibly be integrated in a predictive tool to aid in triaging patients, post-elective PCI.

P1763Derivation and validation of a risk score to predict incomplete ST segment resolution in STEMI patients undergoing primary PCI: association with the benefit of Glycoprotein IIb-IIIa inhibitors Use

Abstract Incomplete ST segment resolution (iSTR) is a well-known marker of poor outcome in patients undergoing primary percutaneous coronary intervention (pPCI) for ST elevation myocardial infarction (STEMI). The use of glycoprotein IIbIIIa inhibitors (GPIs) was suggested to be associated with a survival benefit in high-risk patients. A simple score to predict the risk for developing iSTR could help early identification of these patients and could allow a tailored use of pharmacological tools, such as GPIs. The aim of this study was to create and validate a numerical score to predict iSTR occurrence in STEMI patients undergoing pPCI and to assess its association with the potential benefit of GPIs use. We prospectively enrolled all STEMI patients undergoing pPCI in our University Hospital (2005–2017). iSTR was defined as a &lt;70% resolution of initial ST segment shift in the lead with maximal ST deviation 60 min after reperfusion. Our population was randomly divided in two group: a derivation cohort (60%) and a validation cohort (40%). Potential predictors of iSTR were selected at univariate analysis and were then inserted in a multivariate binary stepwise-backward logistic regression. To create a risk score, numerical values were obtained considering the odds ratio of each independent predictor rounding to the nearest unit or half. A ROC curve with its c-statistic was then used to test the discrimination power of the score both in the derivation and in the validation cohort. Out of a total of 2959 patients, 1774 were included in the derivation: 480 (27%) of them presented iSTR. All-cause mortality at 30 days was significantly higher in patients with iSTR (OR 3.2, 95% CI 2.1–4.9, p&lt;0.001). Anterior MI (OR 2.46, 95% CI 1.90–3.14, p&lt;0.001, score 2.5), anemia at admission (OR 1.76, 95% CI 1.29–2.4, p&lt;0.001, score 2), blood glucose &gt;198 mg/dl at admission (OR 1.77, 95% CI 1.29–2.49, p&lt;0.001, score 2), age &gt;75 years (OR 1.54, 95% CI 1.15–2.10, p=0.004, score 1.5), female sex (OR 1.41, 95% CI 1.06–1.88, p=0.02, score 1.5) and Killip class &gt;2 (OR 1.44, 95% CI 1.05–1.98, p=0.024, score 1.5) were identified as independent predictors of iSTR, creating a ISTR-score that ranged from 0 to 11. The validation cohort consisted in 1185 patients, with 31% showing iSTR. The c-statistic was 0.67 and 0.66 in the derivation and validation cohorts. Patients with score ≥4 versus &lt;4 showed present a worst prognosys but a similar GPI use. Notably, GPIs were associated with a significant survival benefit among patients≥4 but not among patients &lt;4 (Figure). The use of GPIs was not associated to any clinically relevant difference, the increase in bleeding risk appeared similar. A simple pre-procedural risk score may predict iSTR following pPPCI, allowing a rapid risk stratification and the identification of patients who show a favorable risk/benefit ratio for the use of more aggressive strategies such as GPIs. These findings deserve a prospective, randomized evaluation.

P957Survival benefits of routine glycoprotein IIb/IIIa inhibitors during primary PCI in ST-segment elevation myocardial infarction: A meta-analysis of randomised controlled trials

Abstract Background Cardiovascular guidelines recommend adjunct glycoprotein IIb/IIIa inhibitors (GPI) only in selected patients with acute ST-segment elevation myocardial infarction (STEMI). Purpose This study aimed to evaluate routine GPI use in STEMI treated with primary PCI. Methods Online databases were systematically searched for randomised controlled trials (RCTs) of routine GPI vs. control therapy in STEMI. Data from retrieved studies were abstracted and evaluated in a comprehensive meta-analysis using Mantel-Haenszel estimates of risk ratios (RR) as summary statistics. Results After systematic review, twenty-one RCTs with 8,585 patients were included: ten trials randomized tirofiban (T), nine abciximab (A), one eptifibatide (E), one trial used A+T; only one trial used DAPT with prasugrel/ ticagrelor. Routine GPI were associated with a significant reduction in all-cause mortality at 30 days (2.4% (GPI) vs. 3.2%; risk ratio (RR) 0.72; p=0.01) and 6 months (3.7% vs. 4.8%; RR 0.76; p=0.02), and a reduction in recurrent MI (1.1% vs. 2.1%; RR 0.55; p=0.0006), repeat revascularization (2.5% vs. 4.1%; RR 0.63; p=0.0001), TIMI flow &lt;3 after PCI (5.4% vs. 8.2%; RR 0.61; p&lt;0.0001) and ischemic stroke (RR 0.42; p=0.04). Major (4.7% vs. 3.4%; RR 1.35; p=0.005) and minor bleedings (7.2% vs. 5.1%; RR 1.39; p=0.006) but not intracranial bleedings (0.1% vs. 0%; RR 2.7; p=0.37) were significantly increased under routine GPI. Conclusions Routine GPI administration during primary PCI in STEMI resulted in mortality reduction, driven by reductions in recurrent ischemic events – however predominantly in trials pre-prasugrel/ticagrelor. Trials in contemporary STEMI management are needed to confirm these findings.

P3583Optimal procedural strategy to improve clinical outcome in primary percutaneous coronary intervention

Abstract Background Current guideline recommends potent antiplatelet agents and transradial intervention. However, it is uncertain whether routine use of IVUS, thrombus aspiration and glycoprotein IIB-IIIA inhibitor is beneficial for improving clinical outcome in patients with ST-segment elevation myocardial infarction (STEMI). Purpose The aim of this study was to investigate optimal procedural strategy to improve clinical outcome. Methods A total of 6,046 patients who underwent primary percutaneous coronary intervention (PCI) for STEMI were analyzed from the Korean Acute Myocardial Infarction Registry (KAMIR) – National Institute of Health (NIH) database. MACCEs were defined as a composition of all cause death, non-fatal MI, repeat revascularizations including repeated percutaneous coronary intervention and coronary bypass grafting, cerebrovascular accident and rehospitalizations. This research was supported by a fund by Research of Korea Centers for Disease Control and Prevention. Results During the primary PCI, potent antiplatelet agents such as prasugrel and ticagrelor were used in 2342 (38.4%). PCI was performed through transradial approach in 1490 (25.2%). Thrombus aspiration and intravascular ultrasound (IVUS) examination was done in 2204 (36.1%) and 1079 (18.1%), respectively. Glycoprotein IIB-IIIA inhibitor was administered in 1295 (21.7%). Among them, potent antiplatelet agents, transradial intervention, IVUS, and thrombus aspiration significantly reduced MACCEs at 1 year. Glycoprotein IIB-IIIA inhibitor was not effective to improved clinical outcome. In Cox-proportional hazards model, potent antiplatelet agents (hazard ratio 0.82, 95% confidence interval 0.67–0.99; p=0.045) and transradial intervention (hazard ratio 0.61, 95% confidence interval 0.47–0.78; p&lt;0.001) was an independent predictor of MACCEs after adjusting for confounding variables. Combined use of potent antiplatelet agents and transradial intervention (hazard ratio 0.54; 95% confidence interval 0.37–0.80; p=0.002) substantially reduced MACCEs at 1 year. Conclusion Among evidence based procedures during the primary PCI, combined use of potent antiplatelet agents and transradial intervention was optimal procedural strategy to improve clinical outcome.

P6403Predictors of bleeding in elderly patients with myocardial infarction: data from the real world

Abstract Background The population of elderly patients with acute myocardial infarction (MI) is clearly underrepresented in contemporary clinical trials. This population presents a higher risk of both cardiovascular and bleeding events, making the decision of the antithrombotic strategy particularly challenging. Purpose To characterize the antithrombotic therapy used in patients with MI and age ≥75 years, and to identify predictors of major bleeding and cardiovascular events in this population. Methods Retrospective analysis of patients with a diagnosis of MI and age ≥75 years included in the Portuguese Registry of Acute Coronary Syndromes between October 2010 and January 2018. Logistic regression analysis was used to identify predictors of major bleeding and of the combined endpoint of in-hospital mortality and reinfarction. Results The analysis included 17.868 patients of which 30.1% with age ≥75 years. This population had a mean age of 82±5 years, 57% were male and 36% had a diagnosis of STEMI. On admission 10% presented with Killip-Kimball (KK) class III or IV, 14% were on atrial fibrillation (AF), and the mean Hb and creatinine levels were 13±2 g/dl and 1.6±1.2 mg/dl, respectively. In comparison with younger patients, this population had higher Grace and Crusade scores (178 vs 139, and 41 vs 24, respectively). Most elderly patients (74%) underwent coronary angiography (71% by radial artery access) and 75% were submitted to percutaneous revascularization, 9% to surgery, and 1% to an hybrid strategy. Aspirin was used in 96% of patients, clopidogrel in 82%, ticagrelor in 13% (vs 25% of younger patients; p&lt;0.001), and glycoprotein IIb/IIIa inhibitors (GPI) in 11%. Most patients were anticoagulated with enoxaparin (68 vs 56% of younger patients; p&lt;0.001), 22% with unfractionated heparin (vs 30%; p&lt;0.001), and 13% with fondaparinux (vs 14%; p=0.018). Complications were more common in the elderly population, including mechanical complications (1 vs 0.5%), atrioventricular block (5 vs 3%), stroke (1 vs 0.6%), major bleeding (3 vs 1%), in-hospital death (8 vs 2%) and reinfarction (2 vs 1%) (p&lt;0.001 for all). In multivariate logistic regression analysis, the predictors of major bleeding were diastolic blood pressure (BP) on admission &lt;50 mmHg, maximum creatinine ≥2 mg/dl and the use of GPI. The predictors of the combined endpoint were a diagnosis of STEMI, previous history of cancer, chronic kidney disease or demencia, and the presence on admission of an heart rate &lt;60 bpm, systolic BP &lt;90 mmHg or ≥180 mmHg, KK class &gt; I, AF, left bundle branch block, and left ventricle systolic dysfunction. Conclusions This study reflects the contemporary national reality of the management of elderly patients with MI. Overall, this population has a high risk of major bleeding, but several characteristics are associated with an even higher risk, such as the hemodynamic profile, renal function, and the use of GPI.

Use of Glycoprotein IIb/IIIa Inhibitors in the Modern Era of Acute Coronary Syndrome Management: A Survey of Cardiovascular Clinical Pharmacists

Evidence for the use of glycoprotein IIb/IIIa inhibitors (GPIs) in the management of acute coronary syndrome (ACS) is from the era of either limited utilization of P2Y12 inhibitors or prior the introduction of more potent P2Y12 inhibitors. This leads to divergent opinions regarding the role of these agents in contemporary practice. This study sought the opinion of cardiovascular clinical pharmacists regarding the role of GPIs in the modern of ACS management. A 13-question survey was created and distributed from June 2018 to July 2018 via the American College of Clinical Pharmacy’s Cardiology Practice and Research Network e-mail listserv. The survey consisted of questions regarding the ideal use of GPIs in ACS management, preferred agent selection, and rational for selection. All results were analyzed with descriptive statistics. There were a total 69 responses of 1175 (response rate 5.9%). The majority felt there was still a role for GPI in accordance to the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for ST-segment elevation myocardial infarction (65.2%), with eptifibatide being preferred (55.1%). For non-ST-segment myocardial infraction (NSTEMI), only 49.3% felt role of GPI was in line with the ACC/AHA guidelines, but a notable number of respondents felt GPIs were only indicated in NSTEMI patients for bailout or thrombotic complications (18.8%). A majority (56.5%) felt GPIs could be used as an alternative for cangrelor when bridging. The decision to use one agent over another were efficacy data, cost, and pharmacokinetic profile.

Influence of glycoprotein IIb/IIIa inhibitors on bleeding events after successful resuscitation and percutaneous coronary intervention

AimCardiac arrest is the most serious complication in acute coronary syndromes. Glycoprotein IIb/IIIa inhibitors (GPI) are used in selected acute coronary syndrome patients. If the use of GPI leads to an increase in bleeding events and influences survival in patients after cardiac arrest is unknown.MethodsWe report retrospective data of a single center registry of patients after successful intra- and out-of-hospital cardiac arrest between 2002 and 2013. Inclusion criteria were survival for at least 6 h and successful percutaneous coronary intervention (PCI) within the first 24 h. Patients treated with other fibrinolytic agents or being supported by an extracorporeal life support system were excluded from the analysis.Results310 patients were included in our study. 204 received GPI (GPI+), 106 did not (GPI−). Patients in the GPI+ group were significantly younger (62.8 vs. 68.0 years, p < 0.001) and had larger myocardial infarction sizes (maximum creatine kinase 3407 vs. 1450 U/l, p < 0.001). CPR duration, SOFA score and first lactate did not differ between the groups. Any bleeding occurred significantly more often in the GPI+ group (83.3% vs. 67.0%, p = 0.001). Decline of hemoglobin within the first 24 h was higher in the GPI+ group (−1.59 ± 1.71 mg/dl vs. −0.88 ± 1.95 mg/dl, p = 0.004), number of transfused packed red blood cells in the first 4 days, however, were similar (1.18 ± 0.40 vs. 0.90 ± 0.41 packs, p = 0.378). Survival at ICU discharge was significantly higher in the GPI+ group (77.5% vs. 63.2%, p = 0.008). The use of GPI was an independent predictor of hospital survival (OR 3.07, CI 1.31−7.20, p = 0.010). The positive effect for GPI persisted after nearest neighbor propensity score matching including 144 patients (OR 3.27, 95% CI 1.48−7.21, p = 0.003).ConclusionAfter cardiac arrest, bleeding incidence was significantly higher in patients treated with GPI. Incidence of bleedings requiring transfusion, however, was similar. In this retrospective analysis, the use of GPI was an independent predictor of hospital survival. We suggest that GPI may not be withheld from cardiac arrest survivors due to potential risk of bleeding.Graphic abstract