A comparison between upfront high-dose tirofiban versus provisional use in the real-world of non-selected STEMI patients undergoing primary PCI
Insights from the Zwolle acute myocardial infarction registry
First Online: 15 May 2011 DOI:
Cite this article as: Heestermans, A., Hermanides, R., Gosselink, A. et al. Neth Heart J (2010) 18: 592. doi:10.1007/s12471-010-0840-z Background. Despite the proven benefit of glycoprotein IIb/IIIa blockers in patients with acute ST-segment elevation myocardial infarction (STEMI), there is still debate on the timing of administration of these drugs and whether all or only a selection of patients should be treated. We evaluated the effect of routine upfront versus provisional use of high-dose tirofiban (HDT) in a large real-world population of non-selected STEMI patients. Methods. Consecutive STEMI patients were registered in a single-centre dedicated database. Patients with upfront HDT therapy before first balloon inflation were compared with patients who received the drug on a provisional basis, after first balloon inflation. Initial TIMI flow of the infarct-related vessel and enzymatic infarct size and 30-day clinical outcome were assessed. Results. Out of 2679 primary PCI patients HDT was given upfront in 885 (33.0%) and provisionally in 812 (45.3%). Upfront as compared with provisional HDT showed higher initial patency (22.3 vs. 17.9%, p=0.006), smaller infarct size (1401 IU/l (IQR 609 to 2948) vs. 1620 (753 to 3132), p=0.03) and a lower incidence of death or recurrent MI at 30 days (3.3 vs. 5.1%, p=0.04) without an increase in TIMI bleeding (p=0.24). Upfront HDT independently predicted initial patency (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.15 to 1.88, p=0.02), enzymatic infarct size (OR 0.70, 95% CI 0.56 to 0.86, p=0.001) and 30-day death or recurrent MI (OR 0.59, 95% CI 0.37 to 0.95, p=0.03). Conclusion. Our findings support the use of upfront potent antiplatelet and antithrombotic therapy in STEMI patients and encourage further clinical investigations in this field. (Neth Heart J 2010;18:592–7.) Keywords Tirofiban Myocardial Infarction Angioplasty Timing of Drug Administration References
Stone GW, Grines CL, Cox DA, Garcia E, Tcheng JE, Griffin JJ, et al. Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) Investigators. Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction. N Engl J Med. 2002;346:957–966.
De Luca G, Suryapranata H, Stone GW, Antoniucci D, Tcheng JE, Neumann FJ, et al. Abciximab as adjunctive therapy to reperfusion in acute ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. JAMA. 2005;293:1759–1765.
Nienhuis MB, Ottervanger JP, de Boer MJ, Dambrink JHE, Hoorntje JCA, Gosselink ATM, et al. Zwolle Myocardial Infarction Study Group. Prognostic importance of creatine kinase and creatine kinase-MB after primary percutaneous coronary intervention for ST-elevation myocardial infarction. Am Heart J. 2008;155:673–679.
Chesebro JH, Knatterud G, Roberts R, Borer J, Cohen LS, Dalen J, et al. Thrombolysis In Myocardial Infarction (TIMI) trial, phase I: a comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital discharge. Circulation. 1987;76:142–154.
van ‘t Hof AWJ, ten Berg JM, Heestermans T, Dill T, Funck RC, van Werkum JW, et al. Ongoing Tirofiban In Myocardial infarction Evaluation (On-TIME) 2 study group. Prehospital initiation of tirofiban in patients with ST-elevation myocardial infarction undergoing primary angioplasty (On-TIME 2): a multicentre, double-blind, randomised controlled trial. Lancet. 2008;372:537–546.
Van de Werf F, Bax J, Betriu A, Blomstrom-Lundqvist C, Crea F, Falk V, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J. 2008;29:2909–2945.
Budaj A, Brieger D, Steg PG, Goodman SG, Dabbous OH, Fox KA, et al. GRACE Investigators. Global patterns of use of antithrombotic and antiplatelet therapies in patients with acute coronary syndromes: insights from the Global Registry of Acute Coronary Events (GRACE). Am Heart J. 2003;146:999–1006.
Mandelzweig L, Battler A, Boyko V, Bueno H, Danchin N, Fillippatos G, et al. Euro Heart Survey Investigators. The second Euro Heart Survey on acute coronary syndromes: characteristics, treatment, and outcome of patients with ACS in Europe and the Mediterranean Basin in 2004. Eur Heart J. 2006;27:2285–2293.
ten Berg JM, van ‘t Hof AWJ, Dill T, Heestermans T, van Werkum JW, Mosterd A, et al. on behalf of the Ongoing Tirofiban In Myocardial infarction Evaluation (On-TIME) 2 study group. Effect of Early, Pre-Hospital initiation of high-bolus dose tirofiban in patients with ST Elevation Myocardial Infarction on short and long-term clinical outcome. Accepted in JACC.
Ellis SG, Tendera M, de Belder MA, van Boven AJ, Widimsky P, Janssens L, et al. FINESSE Investigators. Facilitated PCI in patients with ST-elevation myocardial infarction. N Engl J Med. 2008;358:2205–2217.
De Luca G, Gibson CM, Bellandi F, Murphy S, Maioli M, Noc M, et al. Early glycoprotein IIb-IIIa inhibitors in primary angioplasty (EGYPT) cooperation: an individual patient data meta-analysis. Heart. 2008;94:1548–558.
Ortolani P, Marzocchi A, Marrozzini C, Palmerini T, Saia F, Taglieri N, et al. Long-term effectiveness of early administration of glycoprotein IIb/IIIa agents to real-world patients undergoing primary percutaneous interventions: results of a registry study in an ST-elevation myocardial infarction network. Eur Heart J. 2009;1:33–43.
Hassan AK, Jukema JW, van der Laarse A, Hasan-Ali H, Wolterbeek R, van der Kley F, et al. Incidence, patient characteristics and predictors of aborted myocardial infarction in patients undergoing primary PCI: prospective study comparing pre- and in-hospital abciximab pretreatment. EuroIntervention. 2009;4:662–668.
Heestermans AA, Van Werkum JW, Hamm C, Dill T, Gosselink ATM, De Boer MJ, et al. Marked reduction of early stent thrombosis with pre-hospital initiation of high-dose Tirofiban in ST-segment elevation myocardial infarction. J Thromb Haemost. 2009;7:1612–1618.
Boersma E, Maas AC, Deckers JW, Simoons ML. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet. 1996;348:771–775.
Stone GW, Witzenbichler B, Guagliumi G, Peruga JZ, Brodie BR, Dudek D, et al. HORIZONS-AMI Trial Investigators. Bivalirudin during primary PCI in acute myocardial infarction. N Engl J Med. 2008;358:2218–2230.
Valgimigli M, Biondi-Zoccai G, Tebaldi M, van ‘t Hof AW, Campo G, Hamm C, et al. Tirofiban as adjunctive therapy for acute coronary syndromes and percutaneous coronary intervention: a meta-analysis of randomized trials. Eur Heart J. 2010;31:35–49.
Heestermans AA, van Werkum JW, Taubert D, Seesing TH, von Beckerath N, Hackeng CM, et al. Impaired bioavailability of clopidogrel in patients with a ST-segment elevation myocardial infarction. Thromb Res. 2008;122:776–781.
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