Title: Glycoprotein IIb/IIIa inhibitors and bivalirudin: under utilised?
1Glycoprotein IIb/IIIa inhibitors and bivalirudin
under utilised?
- Azfar Zaman
- Freeman Hospital
- Newcastle-upon-Tyne
2Conflicts of interest 1. received honoraria
from Eli Lilly, Medicines Company, BMS, Cordis,
Boston Scientific, Abbott 2. received research
funding from Medtronic, Cordis, Boston
Scientific
3Thrombus formation
Targets for antithrombotic treatment
Becker R et al. J Invas Cardiol.
2003Aug(suppI)1-15 and Narayanan S. Ann Clin
Lab Sci. 199929275-280.
4GPI and bivalirudin
- adjunctive antithrombotic to support PCI in
addition to DAP heparin - equivalent ischaemia reduction
- different rates of bleeding, stent thrombosis
5Antithrombotic therapy to support PCI
- what? antiplatelet anticoagulant adjuncive
- who? ACS (troponin pos v troponin neg) stable
- when? pre hospital v hospital
- duration? cath lab only v post procedure infusion
- true cost?
6Antithrombotic therapy to support PCI - what?
- DAP (clopidogrel 600 ASA 300) heparin
- GPI
- bivalirudin
7Clinical presentation who?
diabetes X ISAR-SWEET
ISAR REACT
no diabetes X
NSTE troponin negative X
NSTE troponin positive v ISAR REACT-2
Circulation 20041103527 NEJM
2004350232 JAMA 20062951531 NEJM
2001411895 NEJM 2002346957
STEMI - v
ADMIRAL, CADILLAC
8Under utilised?
- Gold standard
- NICE/AHA/ESC
9(No Transcript)
10Underutilisation?
11GP IIb/IIIa AntagonistsUse by Presentation
CCAD
12Freeman Hospital 2002-2008
13GPI use and non-compliance to NICE Guidelines
Before and after-ISAR-REACT trial
N 1685
Viswanathan G, Zaman A. Guidelines to practice
gap in the use of GPI from ISAR-REACT to over
react? J Interv Cardiol (in press)
14Underutilised - yes
15Underutilisation according to national guidelines
why?
- new era for coronary intervention
- dual antiplatelet therapy (600mg clopidogrel)
- CIAO study do we need heparin for selected low
risk electives? - thrombectomy devices TAPAS study
- changing milieu for ACS patients (no more salvage
PCI ?!)
16Antiplatelet therapy in ACS
ASA
ASA Clopidogrel
ASA Prasugrel
Reduction inIschemicEvents
- 22
- 20
- 19
Increase in Major Bleeds
32
38
60
Single Antiplatelet Rx
Dual Antiplatelet Rx
Higher IPA
17Coronary Interventions Antiplatelets-based Only
(CIAO Study)
JACC 2008521293
18TAPAS Thrombus aspirationTotal mortality at 1
year
Vlaar et al.Lancet 2008
19(No Transcript)
20(No Transcript)
21PCI in 2009
- Paradigm shift in use of adjunctive therapy
during - PCI due to
- effective (oral) antiplatelet therapy
- changing milieu of ACS presentation
- effective thrombus aspiration
- less thrombogenic equipment
22Conclusion
- use of adjunctive therapy for PCI (beyond DAP) is
evolving - largely due to increased potency and safety of
oral antiplatelets and - improved and novel interventional devices
- guidelines for antithrombotic use during PCI need
updating - GPI and bivalirudin underutilised according to
existing guidelines but, in 2009 and beyond,
does it matter?
23Thank you
24HORIZONS AMI Trial Switching Data
UFH pre-procedure was administered to 65.8 of
bivalirudin pts and 76.3 of heparin
GPIIb/IIIa pts
Bivalirudin with "provisional" GP IIb/IIIa
Heparin GP IIb/IIIa
Pint0.47
10
10
Pint0.08
8.5
7.5
8
7.2
8
5.6
5.2
5.2
6
6
4.8
4.6
30-Day Major Bleeding
30-Day MACE
4
4
2
2
RR 95CI 0.81 0.58,1.14
RR 95CI 1.39 0.85,2.28
RR 95CI 0.57 0.42,0.77
RR 95CI 0.69 0.43,1.12
0
0
UFH pretreatment
No UFH
UFH pretreatment
No UFH
(n2,553)
pretreatment
(n2,553)
pretreatment
(n1,042)
(n1,042)
25ACUITY MI and Major Bleeding
UFH/Enoxaparin GPI vs. Bivalirudin GPI vs.
Bivalirudin Alone
P 0.35
P lt0.001
Stone GW et al. NEJM 20063552203-16
26Primary PCI Adjunctive Therapies