ACCAHA UANSTEMI Guidelines: Role of GP IIbIIIa Inhibitors

1
ACC/AHA UA/NSTEMI Guidelines Role of GP
IIb/IIIa Inhibitors
2
ACC/AHA guidelines for UA/NSTEMI GP IIb/IIIa
inhibitors
A platelet GP IIb/IIIa antagonist should be
administered in addition to ASA and heparin to
patients in whom cardiac catheterization and PCI
are planned. GP IIb/IIIa antagonists may also be
administered just prior to PCI.
Eptifibatide or tirofiban should be administered
in addition to ASA and heparin in patients with
continuing ischemia, elevated troponin, or other
high-risk features in whom an invasive management
strategy is not planned.
A platelet GP IIb/IIIa antagonist should be
administered to patients already receiving
heparin, ASA, and clopidogrel in whom cardiac
catheterization and PCI are planned. GP IIb/IIIa
antagonists may also be administered just prior
to PCI.
Braunwald E et al. J Am Coll Cardiol.
2002401366-74.
3
ACC/AHA UA/NSTEMI Guidelines Management of
high-risk patients

• High-risk patients
• Signs of ischemia at rest gt20 minutes AND
  ST-segment depression and/or elevated cardiac
  biomarkers

Diagnostic catheterization and revascularization
within 2448 hours (Class Ia)
Adapted from Braunwald E et al. J Am Coll
Cardiol. 2002401366-74.
4
Mortality risk is lower with early (lt24-hour) GP
IIb/IIIa inhibition
Adjusted OR (95 Cl)
Favorsearly GP IIb/IIIa inhibitor
Favors no early GP IIb/IIIa inhibitor
6 RCTs ACS (N 31,402)
0.91 (0.811.02)
CRUSADE ACS (N 49,378)
0.93 (0.831.05)
CRUSADE Tn (n 32,290)
0.88 (0.771.01)
NRMI NSTEMI (n 60,770)
0.88 (0.790.97)
0.5
1.0
2.0
Odds ratio
Boersma E et al. Lancet. 2002359189-98. Hoekstra
JW et al. Acad Emerg Med. 200512431-8.
RCT randomized control trial Tn troponin
positive
5
Recommended therapies for UA/NSTEMI
Acute therapies (lt24h)
Discharge therapies

• Aspirin
• ?-Blocker
• Heparin (UFH or LMWH)
• GP IIb/IIIa inhibitor (all receiving PCI/cath)
• Clopidogrel (all receiving PCI)
• Catheterization/revascularization 48 hours

• Aspirin
• Clopidogrel
• ?-Blocker
• ACE inhibitor
• Statin/lipid lowering
• Smoking cessation
• Cardiac rehabilitation

Braunwald E et al. J Am Coll Cardiol.
2002401355-74.
6
Majority of ACS patients undergo catheterization
CRUSADE registry data October 1, 2004September
30, 2005 (n 35,897)
Cath
Cath
PCI
PCIlt48 hr
CABG
lt48 hr
CRUSADE. www.crusadeqi.com
Without contraindication to catheterization