Bolus Tirofiban Research Articles

Platelet glycoprotein IIb/IIIa inhibitor tirofiban in clopidogrel-naïve patients undergoing elective percutaneous coronary intervention.

The safety of administration of tirofiban, aplatelet glycoprotein IIb/IIIa inhibitor, followed by aclopidogrel loading dose in clopidogrel-naïve patients undergoing ad-hoc percutaneous coronary intervention (PCI) is not yet clear. In aretrospective observational cohort analysis, clopidogrel-naïve patients undergoing ad-hoc PCI who received ahigh-dose bolus of tirofiban (25 μg/kg) followed by a600-mg clopidogrel loading dose (group1) were compared with patients undergoing elective PCI who were pretreated with clopidogrel (group2), between September 2014 and October 2021. The primary outcome was major adverse cardiovascular events (MACE) defined as the composite of death, myocardial infarction, stroke, target-lesion revascularisation and bleeding at 30days. Secondary outcomes were MACE at 7days and individual components of the primary outcome at 7and 30days. Atotal of 1404 patients were included: 432 (31%) in group1 and 972 (69%) in group2. Median age was 69years, and 28% were female. At 7‑day follow-up, MACE occurred in 1.4% in group1 versus 3.0% in group2 (p = 0.08). 30-day MACE were observed in 1.9% in group1 and 4.2% in group2 (p = 0.03). Secondary outcomes were comparable between the groups. Cox regression analysis, corrected for baseline differences, revealed no significant difference in the primary outcome (hazard ratio:1.8; 95% confidence interval: 0.8-3.9). Ad-hoc PCI in clopidogrel-naïve patients who were treated with high-dose bolus of tirofiban followed by aclopidogrel loading dose immediately after the procedure appeared to be safe.

P213 A COMPLICATED STEMI : POISED BETWEEN THROMBOSIS AND HEMORRHAGE

Abstract The introduction of more effective and powerful antithrombotic therapies has allowed the progressive reduction of ischemic events associated however with an increase in haemorrhagic events. What we are describing is an example of how iatrogenic and non–iatrogenic complications can add up, making routine therapeutic management difficult during and after hospital stay.We are talking about a 50–year–old male patient, a smoker and with a history of dyslipidemia under treatment, who arrived at our cath–lab with a diagnosis of anterior SCA–STEMI, after loading ticagrelor 180 mg from the spoke center where he had gone for chest pain. At coronary angiography, evidence of critical disease of the median anterior interventricular artery treated by primary angioplasty and for the high thrombotic load by thromboaspiration, DES and Tirofiban bolus and 18–hour continuous infusion. Approximately 15 hours after the event, the patient appeared confused and aphasic. A brain CT scan with and without contrast agent was performed which documented the presence of a hemorrhagic focus in the atypical left temporal site, in the absence of arteriovenous malformations not susceptible to surgical therapy (BARC–3). Therefore, in view of the high risk of bleeding, de–escalation therapy with cardioaspirin and clopidogrel was practiced. Five days after the event, the clinical picture was complicated again by the finding of apical thrombosis on the transthoracic ultrasound. For this reason, given the stability of the haemorrhagic lesion on CT scans and control MRIs, Enoxaparin sodium 4000 IU was introduced in therapy once, with resolution of the formation in the imaging control after one month. The patient was then discharged with indication for short–DAPT in consideration of the high PRECISE–DAPT score. The arduous task of managing this case led us to reflect on the importance of the pre– and post–PCI clinical picture of the patient in order to seek the appropriate antithrombotic treatment by dynamically balancing the ischemic and haemorrhagic risk during hospitalization through numerous standardized tools at our disposal.

P305 MULTIVESSEL SUBACUTE STENT THROMBOSIS

Abstract The presence of comorbidities such as psychiatric pathologies negatively influences the prognosis of patients with acute cardiovascular events. A 62–year–old male patient suffering from arterial hypertension, dyslipidemia, ischemic heart disease, treated 3 years earlier with PCI of LAD, Cx e RCA (EF 45%), and schizophrenia, is hospitalized with a diagnosis of NSTEMI. Coronary angiography shows: eccentric stenosis 70% proximal to the pre–existing stent in the middle LAD; Intrastent occlusion of the middle circumflex branch with omocoronary rehabilitation and ulcerated critical plaque in the proximal segment of the right coronary artery with mild intrastent restenosis in the middle. The patient refuses cardiac surgery, so angioplasty with ultra–thin drug–eluting stents is performed. The patient starts DAPT with clopidogrel, choosing a combination formulation to promote compliance, with discharge on the fourth day. Three days after discharge, the patient returns with anterior STEMI, with multivessel intrastent thrombotic closure (LAD, Cx, RCA), so angioplasty with paclitaxel–releasing balloon is performed on LAD and with NC balloons on the right coronary artery; impossibility to obtain total recanalization of the circumflex branch due to the non–transit of guides, even hydrophilic and of different weights. During angioplasty and for the following 12 hours, bolus and infusion of tirofiban is administered due to the high thrombotic burden. The choice of the second antiplatelet agent in this second procedure fell on prasugrel. The patient is discharged on the sixth day and a long conversation is held with his wife regarding the correct management of the home therapy. One year later, the patient a dual–chamber ICD was implanted at another centre, with correct and regular assumption of home therapy. Our case demonstrates an infrequent form of multivessel thrombosis during STEMI. The presence of schizophrenia influences negatively the evolution of the natural history of ischemic cardiopaty. The psychiatric substrate exposes to a greater number of cardiovascular events, given the reduced therapeutic compliance, also as regards the choice of appropriate therapeutic strategies. A joint path between the hospital, local medicine and the family environment would be desirable in order to correctly manage this type of patient.

P135 A CASE OF RIGHT CORONARY ARTERY ANEURYSM COMPLICATED BY ENDOVASCULAR THROMBOSIS

Abstract Coronary artery aneurysm is a rare disorder with prevalence in male population. The most commonly involved vessel is the right coronary artery followed by the anterior descending artery. The most frequent etiologies are coronary atherosclerosis and Kawasaki disease. The treatment of coronary aneurysms with significant stenosis is often surgical, with implantation of covered stents in case of saccular aneurysms. In coronary artery aneurysms without significant stenosis, medical therapy is often the most suitable choice. Case report We present a case of a 68–year–old man with history of hypertension and dyslipidemia, who arrived to our ED with inferior STEMI. Left coronary angiography showed a 75% stenosis of the distal anterior descending artery and subocclusion of the first left marginal artery. Right coronary angiography revealed a severely ectatic vessel (7–8 mm diameter) with intraluminal thrombosis and markedly slowed flow (TIMI 1). Considering the regression of symptoms and ECG alterations, intracoronary bolus of Tirofiban was performed followed by i.v. infusion of 24 hours in association with DAPT. Blood tests did not detect any relevant alterations of coagulation profile but only an heterozygous mutation for MTHFR with slightly altered homocysteine values. Six days later, a second coronary angiography was performed which confirmed the persistence of thrombotic formation into the right coronary artery that was treated with rheolytic thromboaspiration and TIMI 2 final flow. In consideration of the angiographic findings, it was decided not to implant coronary stents. After multidisciplinary team discussion it was decided to associate DAPT with oral anticoagulant therapy (Warfarin 5 mg, INR 2–3) The patient was discharged with indication to continue the triple antithrombotic therapy for 6 months followed by double antithrombotic therapy with ASA and Warfarin. Conclusions Coronary aneurysms in the context of ACS are rare findings, often caused by endovascular thrombosis. Thrombolytic therapy, rheolytic thromboaspiration and anticoagulation therapy are valid tools for the successful treatment of such cases.

Comparison of Intracoronary and Intravenous Administration of High Dose Bolus Tirofiban in Patients of St Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Acute ST-elevation myocardial infarction (STEMI) is a condition in which transmural myocardial ischemia causes myocardial necrosis and is the leading cause of death. Objectives: To compare the efficacy of tirofiban bolus administration via percutaneous coronary intervention (PCI) and intravenous route (IV) in STEMI patients for restoration of myocardial perfusion. Methods: A retrospective cross-sectional study was conducted at Cardiology Department, Hayatabad Medical Complex, Peshawar, during 2021-22. The study comprised 168 STEMI patients divided into Group A and B (n=84), treated with tirofiban PCI and IV route, respectively. Results: Incidence of STEMI was three folds higher in males than females, and the mean age of the patients was 55 years. Smoking and obesity were the potential risk factors. Patients in Group A had a better clinical outcome and prognosis than Group B. In comparison to the IV treatment group (91.66%), the ST-segment resolution time was considerably lower (P<0.05) in the PCI group (48.80%). In both groups, the observational parameters for TIMI flow grade, TIMI major and minor bleeding, MBG, and MACE were not-significantly different (P≥0.05), comprising percentages 94, 3.57, 9.52, 71.42, 5.95%, and 84.52, 2.38, 13.09, 75, 15.47%, respectively. In comparison to IV therapy group, the LVEF percentage in PCI group was statistically significant (P<0.05) after 24 hours and 30 days (57, 63 and 52, 58%, respectively). Conclusions: It was concluded that STEMI patients treated with PCI tirofiban bolus had significantly greater (p<0.05) recovery rates, left ventricular ejection fractions and better clinical outcomes than IV-treated group

Application of tirofiban in patients with acute myocardial infarction complicated with diabetes and undergoing emergency interventional therapy

ABSTRACTObjectives:To investigate the application of tirofiban in patients with acute myocardial infarction complicated with diabetes and undergoing emergency interventional therapy.Methods:Two hundred patients with acute ST-segment elevation myocardial infarction (STEMI) complicated with diabetes who underwent percutaneous coronary intervention (PCI) and found to have high thrombus burden in coronary artery admitted to our hospital from September 2018 to September 2020 were selected as subjects, and were divided into two groups according to the randomization method: the intravenous tirofiban bolus group and the intracoronary tirofiban bolus group, with 100 cases in each group. The levels of LVEF, LVESD and LVEDD were detected immediately after admission and 15 days after therapy, and the enzyme-linked immunosorbent assay was utilized to detect the levels of CK-MB, MMP-9 and hs-CRP. Furthermore, the levels of BNP, TNI, CR and UREA of the patients were analyzed, and the levels of ESR and FIB were detected with an automatic blood rheology analyzer to analyze the TIMI classification and the incidence of MACE in the two groups.Results:Significant differences were seen between the two groups in the levels of various indicators after therapy. Fifteen days after therapy, the levels of LVEF and LVEDD were higher and the level of LVESD was lower in the intracoronary tirofiban bolus group than in the intravenous tirofiban bolus group (p<0.05); 3d after therapy, the levels of CK-MB, MMP-9 and BNP in the intracoronary tirofiban bolus group were lower than those in the intravenous tirofiban bolus group (p<0.05); 3d after therapy, the levels of TNI (p<0.05), CR and UREA in the intracoronary tirofiban bolus group were lower than those in the intravenous tirofiban bolus group, with no statistical difference (p>0.05); Similarly, 3d after therapy, the levels of TNI, Cr and Urea, as well as ESR, FIB and hs-CRP were lower in the intracoronary tirofiban bolus group than in the intravenous tirofiban bolus group (p<0.05). Compared with the intravenous tirofiban bolus group, the intracoronary tirofiban bolus group had a lower number of patients with Grade-0 and Grade-1, but a higher number of patients with Grade-2 and Grade-3 (p<0.05); Moreover, the incidence of MACE in the intracoronary tirofiban bolus group was lower than that in the intravenous tirofiban bolus group (p<0.05).Conclusion:In patients with STEMI complicated with diabetes who underwent PCI and found to have high thrombus burden in coronary artery, intracoronary bolus of tirofiban boasts superior therapeutic efficacy over intravenous bolus of tirofiban in significantly improving cardiac function, reducing myocardial cell damage, and improving renal function and myocardial inflammation of patients.

The Prophylactic Use of Tirofiban versus Oral Antiplatelet Medications in Stent-Assisted Coiling of Intracranial Aneurysms: A Meta-analysis.

The protocol for optimal antiplatelet therapy to prevent thromboembolic and hemorrhagic complications in patients with cerebral aneurysms using an endovascular approach is not clear. Our study analyzed the safety and efficacy of prophylactic tirofiban administration compared with oral antiplatelet drug therapy. We used the PubMed, EMBASE, MEDLINE, and Cochrane library data bases. Our study consisted of all case series with >5 patients that reported treatment-related outcomes of patients undergoing endovascular procedures pretreated with tirofiban or oral antiplatelet drug therapy. Random effects or fixed effects meta-analysis was used to pool the cumulative rate of complications, perioperative mortality, and good clinical outcomes. Fifteen studies with 1981 patients were registered. Thromboembolic complications were significantly lower in the tirofiban group (3.6%; 95% CI, 1.9%-5.8%) compared with the dual-antiplatelet therapy group (8.5%, 95% CI, 4.5%-13%; P = .04). Pretreatment with tirofiban did not remarkably increase the rate of hemorrhagic complications (3.5%; 95% CI, 1.8%-5.6%) compared with dual-antiplatelet therapy (5.1%; 95% CI, 2.6%-8.5%; P = .371). There was a trend toward lower perioperative mortality with tirofiban (0.8%; 95% CI, 0.2%-1.6%) compared with dual-antiplatelet therapy (1.2%; 95% CI, 0.7%-2.0%; P = .412). There was no significant difference in the safety and efficacy between the tirofiban bolus plus drip and drip alone. The limitations are selection and publication biases. Prophylactic therapy with tirofiban resulted in significantly lower rates of thromboembolic complications with no increase in hemorrhagic events or mortality than the prophylactic use of dual-antiplatelet therapy.

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.

Safety and Efficacy of Tirofiban for Acute Ischemic Stroke Patients With Large Artery Atherosclerosis Stroke Etiology Undergoing Endovascular Therapy.

Objective: To investigate the safety and efficacy of tirofiban in acute ischemic stroke (AIS) patients with large artery atherosclerosis (LAA) stroke etiology receiving endovascular therapy (EVT).Methods: In this multi-center prospective study, patients who were considered to have an indication received a low dose intra-arterial bolus (0.25–1 mg) of tirofiban. The safety and efficacy outcomes at 90-day follow-ups included symptomatic intracranial hemorrhage (sICH), recanalization rate, functional outcome, and mortality.Results: Among the 649 AIS patients with LAA, those in the tirofiban group (n = 244) showed higher systolic blood pressure (BP) and NIHSS score on admission, puncture-to-recanalization time, lower frequency of intravenous thrombolysis and intra-arterial thrombolysis, higher frequency of antiplatelet, heparinization, mechanical stent retrieval, aspiration, balloon angioplasty, and more retrieval times compared with those in the non-tirofiban group (n = 405) (all P < 0.05). Tirofiban was found to be associated with superior clinical outcomes in anterior circulation stroke and major stroke patients [adjusted odds ratio (OR) = 2.163, 95% confidence interval (CI) = 1.130–4.140, P = 0.02 and adjusted OR = 2.361, 95% CI = 1.326–4.202, P = 0.004, respectively] and a lower risk of mortality at 90-day follow-ups (adjusted OR = 0.159, 95% CI = 0.042–0.599, P = 0.007 and adjusted OR = 0.252, 95% CI = 0.103–0.621, P = 0.003, respectively). There was no significant difference in sICH between the two groups.Conclusions: Tirofiban in AIS patients with LAA undergoing EVT is safe and may benefit the functional outcomes in anterior circulation and major stroke patients and showed a trend for reduced mortality.

Efficacy and safety of single high-dose versus double high-dose intracoronary bolus tirofiban in patients with ST-segment elevation myocardial infarction

Objectives: We evaluated the efficacy and safety of single high-dose versus double high-dose intracoronary bolus tirofiban in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Methods: A total of 80 patients, who were admitted to our clinic and underwent primary PCI, were included in this observational cohort study. The patients were divided into the single high-dose group (n = 40) and the double high-dose group (n = 40) according to the intracoronary bolus tirofiban regime. The primary endpoint was assumed as the incidence of major adverse cardiac event (s) (MACE) defined as all-cause mortality and repeat coronary revascularization (target vessel revascularization [TVR]) at 30 days. MACE and bleeding events were evaluated at 7 and 30 days. Results: The primary endpoint was not significantly different between the single and the double high-dose groups (40.0% vs. 17.5%, p = 0.994). However, a significantly lower 30-day TVR rate was observed in the double high-dose group (27.5% vs. 7.5%, p = 0.019). No significant difference was observed in terms of 30-day all-cause mortality between the two groups (12.5% vs. 10.0%, p = 0.712). Major bleeding events were not observed in any group. Multivariate logistic regression analysis demonstrated that CRUSADE score (Hazard ratio [HR]: 5.721; 95% CI: 2.036 to 16.073, p = 0.001) and platelet count (HR: 1.009; 95% CI: 1.000 to 1.018, p = 0.048) were the independent predictors of bleeding at 7 days. Conclusions: Double high-dose intracoronary bolus tirofiban in STEMI patients undergoing primary PCI was associated with significantly lower 30-day TVR rates without an increase in bleeding events. However, it did not significantly affect MACE and all-cause mortality rates.

Platelet Inhibition With IV Glycoprotein IIb/IIIa Inhibitor to Prevent Thrombosis in Pediatric Patients Undergoing Aortopulmonary Shunting.

Shunt thrombosis, a potential complication of aortopulmonary shunting, is associated with high mortality. Commonly used oral antiplatelet drugs such as aspirin demonstrate variable absorption and inconsistent antiplatelet effect in critically ill patients early after surgery. IV glycoprotein IIb/IIIa inhibitors are antiplatelet agents with rapid and reproducible effect that may be beneficial as a bridge to oral therapy. Retrospective review of pediatric patients undergoing treatment with IV tirofiban. Discarded blood samples were used to determine pharmacokinetic parameters. Pediatric cardiac ICU at a single institution. Fifty-two pediatric patients (< 18 yr) undergoing surgical aortopulmonary shunt procedure who received tirofiban infusion as a bridge to oral aspirin. None. Primary outcome measures were shunt thrombosis and bleeding events, whereas secondary outcomes included measurement of platelet inhibition by thromboelastography with platelet mapping and pharmacokinetic analysis (performed in a subset of 15 patients). Shunt thrombosis occurred in two of 52 patients (3.9%) after prophylaxis treatment with tirofiban; both thrombosis events occurred after discontinuation of the drug. One patient (1.9%) experienced bleeding complication during the infusion. A tirofiban bolus of 10 µg/kg and infusion of 0.15 µg/kg/min resulted in significantly increased platelet inhibition via adenosine diphosphate pathway (median 66% [43-96] pre-tirofiban compared with 97% [92-99%] at 2 hr; p < 0.05). Half-life of tirofiban in plasma was 142 ± 1.5 minutes, and the average steady-state concentration was 112 ± 62 ng/mL. Age and serum creatinine were significant covariates associated with systemic clearance. Dosing simulations were generated based upon one compartment model. IV glycoprotein IIb/IIIa inhibitor as a bridge to oral antiplatelet therapy is safe in pediatric patients after aortopulmonary shunting. Dosing considerations should include both age and renal function. Randomized trials are warranted to establish efficacy compared with current anticoagulation practices.

In Reply: The Safety and Efficacy of Continuous Tirofiban as a Monoantiplatelet Therapy in the Management of Ruptured Aneurysms Treated Using Stent-Assisted Coiling or Flow Diversion and Requiring Ventricular Drainage.

Background Hemorrhagic complications are a major concern for aneurysmal subarachnoid hemorrhage patients treated with stenting or stent-assisted coiling and undergoing additional procedures such as shunting, ventriculostomy placement, and craniotomies/craniectomies. Objective To assess the safety and efficacy of using a continuous infusion of tirofiban as a monoantiplatelet therapy in the management of ruptured aneurysms in the setting of either stent-assisted coiling (SAC) or flow diversion devices (FDD) in patients requiring either an external ventricular drain (EVD) or ventriculoperitoneal shunt (VPS). Methods Aneurysmal subarachnoid hemorrhage (aSAH) patients between July 2017 and September 2018 who were treated with SAC or FDD were started on a continuous tirofiban infusion protocol (0.10 μg/kg/min) with no preceding loading dose as a monoantiplatelet therapy. Safety analysis was performed retrospectively to assess the complication rate, hemorrhagic rate, and rate of ischemic events. There were no hemorrhages related to the VPS surgery. Results Nineteen subjects were included in the series. The patients received a total of 25 procedures that included 19 EVDs and 6 VPSs. Two patients (8.3%) developed small asymptomatic track hemorrhages after EVD placement. One patient developed a large retroperitoneal hemorrhage due to renal artery branch injury during procedure, and another patient developed an idiosyncratic transient thrombocytopenia which resolved after stopping the medication. One patient (4%) developed a transient ischemic attack, which resolved after a bolus of tirofiban. Conclusion Our study suggests that long-term use of intravenous tirofiban monotherapy in aSAH subjects for endovascular SAC or FDD is safe in the perioperative setting.

The Safety and Efficacy of Continuous Tirofiban as a Monoantiplatelet Therapy in the Management of Ruptured Aneurysms Treated Using Stent-Assisted Coiling or Flow Diversion and Requiring Ventricular Drainage.

Hemorrhagic complications are a major concern for aneurysmal subarachnoid hemorrhage patients treated with stenting or stent-assisted coiling and undergoing additional procedures such as shunting, ventriculostomy placement, and craniotomies/craniectomies. To assess the safety and efficacy of using a continuous infusion of tirofiban as a monoantiplatelet therapy in the management of ruptured aneurysms in the setting of either stent-assisted coiling (SAC) or flow diversion devices (FDD) in patients requiring either an external ventricular drain (EVD) or ventriculoperitoneal shunt (VPS). Aneurysmal subarachnoid hemorrhage (aSAH) patients between July 2017 and September 2018 who were treated with SAC or FDD were started on a continuous tirofiban infusion protocol (0.10 μg/kg/min) with no preceding loading dose as a monoantiplatelet therapy. Safety analysis was performed retrospectively to assess the complication rate, hemorrhagic rate, and rate of ischemic events. There were no hemorrhages related to the VPS surgery. Nineteen subjects were included in the series. The patients received a total of 25 procedures that included 19 EVDs and 6 VPSs. Two patients (8.3%) developed small asymptomatic track hemorrhages after EVD placement. One patient developed a large retroperitoneal hemorrhage due to renal artery branch injury during procedure, and another patient developed an idiosyncratic transient thrombocytopenia which resolved after stopping the medication. One patient (4%) developed a transient ischemic attack, which resolved after a bolus of tirofiban. Our study suggests that long-term use of intravenous tirofiban monotherapy in aSAH subjects for endovascular SAC or FDD is safe in the perioperative setting.

Safety of Intra-Arterial Tirofiban Administration in Ischemic Stroke Patients after Unsuccessful Mechanical Thrombectomy

PurposeTo assess the safety of low-dose intra-arterial (IA) tirofiban bolus after unsuccessful mechanical thrombectomy in patients with ischemic stroke due to large artery occlusion in anterior cerebral circulation. Materials and MethodsPatients with ischemic stroke who were treated with mechanical thrombectomy were enrolled in a multicenter registry. Low-dose tirofiban was injected into the residual arterial thrombus in patients after unsuccessful mechanical thrombectomy. The major safety measurement was defined as symptomatic intracranial hemorrhage (SICH). The functional outcome at 90 days was assessed with the modified Rankin Scale, and a score of 0–2 was defined as favorable. ResultsOf the 632 enrolled patients, 154 (24.4%) received IA tirofiban treatment. The SICH rate was 13.6% (21/154) in patients with tirofiban and 16.7% (80/478) in patients without tirofiban (P = .361). IA tirofiban was not associated with increased risk of SICH (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.36–1.31; P = .26). IA tirofiban treatment did not increase the risk of mortality at 90 days of the index stroke (OR, 0.66; 95% CI, 0.36–1.31; P = .15). Patients with large artery atherosclerosis stroke who were treated with tirofiban were associated with decreased risk of death (OR, 11.3% vs 23.4%; P = .042) compared to patients who were not treated with tirofiban. ConclusionsLow-dose IA tirofiban administration may be relatively safe in patients with ischemic stroke after unsuccessful recanalization.

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.

Abstract WP18: Tirofiban Cannot Prevent the Early Re-Occlusion After Endovascular Therapy in Acute Ischemic Stroke Patients

Endothelial injury is inevitable after Endovascular thrombectomy (ET) in acute ischemic stroke, which may lead to early re-occlusion and attenuate the beneficial effects of ET. Tirofiban, a Glycoprotein(GP) IIb/IIIa antagonist, is often used to prevent local platelet aggregation and early re-occlusion. However, its effectiveness in preventing early re-occlusion is still unknown. Here, we investigate the efficacy of tirofiban in preventing early re-occlusion after ET. This observational study was based on a registry study. AIS patients treated with ET were recruited if they met one of the following criteria: treated with permanent intracranial stenting, balloon angioplasty, or &gt;3 passes with retriever during thrombectomy. If used, a low dose bolus tirofiban (0.25 to 0.5 mg) was administrated intraarterially, followed by intravenous tirofiban continuously at a rate of 0.2 to 0.25 mg/h for 12 to 24 hours. Re-occlusion was defined as an in-situ re-thrombosis assessed by TCD and/or CTA within 7 days after ET. The primary outcome was the incidence of early re-occlusion within 7 days post-treatment. Eight one subjects (aged 60.6±12.2 years old) were included. There were 48 subjects treated with tirofiban and 33 subjects not treated with tirofiban. The median NIHSS at admission was 18 (12.5-25.5). Compared with 3 subjects (9.1%) treated without tirofiban, 4 subjects (8.0%) treated with tirofiban experience re-occlusion ( p =0.905). In Multivariate logistic regression analysis, tirofiban was also not associated with early re-occlusion ( p &gt;0.05). 15 subjects (31.3%) experienced ICH in tirofiban group, compared with 13 (39.4%) in non-tirofiban group ( p =0.449). For sICH, 2 subjects (4.2%) from the tirofiban group versus 6 (18.2%) subjects from the tirofiban group ( p =0.089). At 3 months follow-up, compared with subjects treated without tirofiban, more subjects treated with tirofiban achieved independent walking ability (mRS 0-3) (18.2% vs. 2.0%, P =0.033). For a long term follow-up with a median time of 16 (2.5-28.0) months, no significant differences were found between two groups ( p &gt;0.05). In conclusion, adjunct tirofiban in AIS patients treated with ET may not prevent early re-occlusion. But it may improve the functional outcome at 3 months after ET.

Intracoronary high-dose bolus tirofiban administration during complex coronary interventions: A United States-based case series

The GP IIb/IIIa inhibitors (GPIs) rapidly provide therapeutic levels of platelet aggregation inhibition and serve as adjunct pharmacotherapy to oral P2Y12 inhibitors that exhibit a significant delay in onset of action for patients with Acute Coronary Syndrome (ACS). Intracoronary (IC) administration of the high dose bolus (HDB) tirofiban has not been extensively studied. Compared to intravenous delivery, IC administration can lead to higher local drug concentration and, therefore, provide instantaneous disruption of platelet aggregation in the culprit vessel. This report describes the successful resolution of thrombus using IC HDB tirofiban in 7 high-risk coronary interventions with complications such as recurrent thrombosis and cardiogenic shock in ACS patients. This report represents the first case series of IC HDB tirofiban performed in North America and suggests that IC HDB tirofiban may represent an effective and safe strategy to achieve rapid thrombus resolution in ACS patients.

High-dose bolus tirofiban versus low-dose bolus in patients with acute coronary syndrome undergoing percutaneous coronary intervention.

Aim of the present study was to determine effects of high-dose versus low-dose intravenous (IV) bolus tirofiban on angiographic measures, ST resolution, enzymatic infarct size, and clinical outcomes in patients with acute coronary syndrome (ACS) who were undergoing percutaneous coronary intervention (PCI) and received current pharmacoinvasive therapy. Acute coronary syndrome patients (n=271, 85.6% male; mean age: 57.9±12.6 years) from between 2009 and 2015 who received IV tirofiban therapy following PCI were retrospectively analyzed. All patients had received maintenance tirofiban infusion (0.15 µg/kg/min) after bolus dose and 600 mg clopidogrel. Percentage of patients undergoing drug eluting stent implantation procedure was 33.5%. Tirofiban was administered to all patients in bailout situation or for thrombotic complication after PCI. High-dose IV bolus group (25 µg/kg; n=140) was associated with greater ST segment resolution (66% vs. 50%, p=0.013) and reduced peak troponin release [12.4 ng/dL (range: 6.5-21.5 ng/dL) vs. 16.4 ng/dL (range: 10.1-27.4 ng/dL), p=0.001] compared with low-dose bolus group (10 µg/kg, n=131). Cardiovascular event rates were similar between groups at in-hospital, 1-month, and 6-month follow-up (p=1.000, 1.000, and 0.287, respectively). Percentage of patients with post-procedural Thrombolysis in Myocardial Infarction (TIMI) grade III flow, major, and minor bleeding were similar (p=0.085, 1.000, and 0.965, respectively). Use of high-dose IV bolus tirofiban in addition to aspirin and high-dose clopidogrel improves ST segment resolution, reduces infarct size, and does not increase bleeding events in patients with ACS undergoing PCI compared with low-dose bolus. Angiographic measures and clinical endpoints were similar between groups.

Comparison of heparin, bivalirudin, and different glycoprotein IIb/IIIa inhibitor regimens for anticoagulation during percutaneous coronary intervention: A network meta-analysis.

Numerous GPIs are available for PCI. Although they were tested in randomized controlled trials, a comparison between the different GPI strategies is lacking. Thus, we performed a Bayesian network meta-analysis to compare different glycoprotein IIb/IIIa inhibitor (GPI) strategies with heparin and bivalirudin for percutaneous coronary intervention (PCI). MEDLINE, Cochrane CENTRAL, and ClinicalTrials.gov were searched by two independent reviewers for randomized controlled trials comparing high-dose bolus tirofiban, abciximab, eptifibatide, heparin with provisional glycoprotein IIb/IIIa inhibitors, and bivalirudin with provisional GPI that reported clinical outcomes. Mixed treatment comparison model generation was performed to directly and indirectly compare between different anticoagulation strategies for all-cause mortality, myocardial infarction, major adverse cardiovascular events, major bleeding, minor bleeding, need for transfusion, and thrombocytopenia. A total of 41 randomized controlled trials with 38,645 patients were included in the analysis, among which 2654 were randomized to high-dose bolus tirofiban, 6752 to abciximab, 1669 to eptifibatide, 16,500 to heparin, and 11,070 to bivalirudin. Mean age was 64±11years, 75% were male, 91% were treated with stenting, 71% with clopidogrel, and 74% for acute coronary syndrome. High-dose bolus tirofiban was associated with a significant reduction in all-cause mortality compared with heparin (OR 0.57 [credible intervals 0.37, 0.9]) and eptifibatide (OR 0.44 [credible intervals 0.19, 1.0]). GPI regimens had less myocardial infarction and major adverse cardiovascular events but greater bleeding compared with heparin and bivalirudin. There was no difference among the GPI therapies for other outcomes, including myocardial infarction, major adverse cardiovascular events, and major bleeding. Our network meta-analysis of 38,645 patients demonstrated that GPI regimens were associated with a reduction in recurrent myocardial infarction or major adverse cardiovascular events for PCI, while bivalirudin was associated with the lowest risk of bleeding.

Effect of intracoronary tirofiban bolus administration on platelet-derived microparticles and short-term clinical benefit in patients with acute ST-segment elevation myocardial infarction

Objective To investigate the effect of intracoronary tirofiban bolus administration on platelet-derived microparticles (PMPs) and its correlation with the short-term clinical benefit in patients with acute ST-segment elevation myocardial infarction (ASTEMI) undergoing emergency percutaneous coronary intervention (PCI). Methods A total of 90 patients with ASTEMI undergoing emergency PCI were selected and randomized into the intracoronary group (intracoronary tirofiban 10.00 μg/kg bolus within 1-3 min followed by intravenous continuous infusion at 0.15 μg·kg-1·min-1 for 36 h, n=30), intravenous group (intravenous tirofiban 10.00 μg/kg bolus within 1-3 min followed by intravenous continuous infusion at 0.15 μg·kg-1·min-1 for 36 h, n=30) and control group (without tirofiban administration, n=30). The 3 ml blood samples from coronary artery were obtained before and 10 min after tirofiban infusion. The 3 ml blood samples from radial artery were collected 24 hours after tirofiban infusion and 12 hours after drug withdrawal. The counts of PMPs were analyzed by flow cytometry. The thrombolysis in myocardial infarction (TIMI) flow grade classification and TIMI Myocardial Perfusion Grade in the culprit blood vessel after PCI, and the incidences of bleeding and major adverse cardiac events (MACE) within 30 days after surgery were recorded. Results There was no significant difference in baseline of PMPs among intracoronary group, intravenous group and control group (all P>0.05). The level of PMPs was decreased in the intracoronary and intravenous group as compared with the control group 〔(3.6±2.3)%, (5.1±2.7)% vs. (6.7±3.2)%, P 0.05), and PMPs levels were lower in intracoronary and intravenous group than in control group (both P 0.05). Immediately after PCI, the TIMI flow grade and TIMI myocardial perfusion grade in the culprit blood vessel in intracoronary group were superior to those in the intravenous group and control group (P 0.05). Conclusions The intracoronary versus intravenous tirofiban administration can effectively and immediately reduce the number of PMPs in patients with acute ST-segment elevation myocardial infarction undergoing emergency interventional treatment, quickly inhibit the activated platelets, and decrease the total major adverse cardiovascular events without increasing the risk of bleeding. Key words: Myocardial infarction; Blood platelets; Angioplasty, intervention, percutaneous coronary