Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial treatment of non-ST segment elevation acute coronary syndromes

Bosch X, Marrugat J, Sanchis J

Published Online:

September 8, 2010

During the last two decades, doctors have been looking for the best treatment to prevent clots in the coronary arteries of patients with coronary heart disease. This review summarises the results of 48 studies which used a potent class of intravenous antiplatelet drug - glycoprotein IIb-IIIa blockers. This treatment was tested in two different conditions: in patients undergoing percutaneous coronary intervention (PCI) procedures (coronary angioplasty with or without stenting), and as the initial treatment of patients hospitalised for acute coronary syndromes (unstable angina and non-ST segment elevation acute myocardial infarction).

Overall, the use of these drugs during PCI reduced the risk of death and of death or myocardial infarction at 30 days and at 6 months. The results were similar for stable and for unstable patients with coronary artery disease, but there was comparatively less benefit for patients previously treated with clopidogrel, a new oral antiplatelet drug. However, these drugs only slightly reduced the risk of death or myocardial infarction when administered as initial medical treatment in patients with unstable angina or non-ST-elevation myocardial infarction. The benefits of glycoprotein IIb/IIIa blockers need to be balanced against the increased risk of severe bleeding.

Abstract (click to read)

Background:

During percutaneous coronary intervention (PCI), and in non-ST segment elevation acute coronary syndromes (NSTEACS), the risk of acute vessel occlusion by thrombosis is high. IIb/IIIa blockers strongly inhibit platelet aggregation and may prevent mortality and myocardial infarction (MI). This is an update of a Cochrane review first published in 2001, and previously updated in 2007.

Objectives:

To assess the effects and safety of IIb/IIIa blockers when administered during PCI, and as initial medical treatment in patients with NSTEACS.

Search strategy:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 3, 2009), MEDLINE (1966 to October 2009), and EMBASE (1980 to October 2009).

Selection criteria:

Randomised controlled trials comparing intravenous IIb/IIIa blockers with placebo or usual care.

Data collection and analysis:

Two authors independently selected studies for inclusion, assessed trial quality and extracted data. We collected major bleeding as adverse effect information from the trials. Odds ratios (OR) and 95% confidence intervals (CI) were used for effect measures.

Main results:

Forty-eight trials involving 62,417 patients were included. During PCI, IIb/IIIa blockers decreased mortality at 30 days (OR 0.76, 95% CI 0.62 to 0.95) and at six months (OR 0.84, 95% CI 0.71 to 1.00). Death or MI was decreased both at 30 days (OR 0.65, 95% CI 0.60 to 0.72), and at 6 months (OR 0.70, 95% CI 0.61 to 0.81), although severe bleeding was increased (OR 1.38, 95% CI 1.20 to 1.59; absolute risk increase (ARI) 8.0 per 1000). The efficacy results were homogeneous for every endpoint according to the clinical condition of the patients, but were less marked for patients pre-treated with clopidogrel, especially in patients without ACS.

As initial medical treatment of NSTEACS, IIb/IIIa blockers did not decrease mortality at 30 days (OR 0.91, 95% CI 0.80 to 1.03) or at six months (OR 1.00, 95% CI 0.87 to 1.15), but slightly decreased death or MI at 30 days (OR 0.92, 95% CI 0.86 to 0.99) and at six months (OR 0.88, 95% CI 0.81 to 0.96), although severe bleeding was increased (OR 1.27, 95% CI 1.12 to 1.43; ARI 1.4 per 1000).

Authors' conclusions:

When administered during PCI, intravenous IIb/IIIa blockers reduce the risk of death and of death or MI at 30 days and at six months, at a price of an increase in the risk of severe bleeding. The efficacy effects are homogeneous but are less marked in patients pre-treated with clopidogrel where they seem to be effective only in patients with ACS. When administered as initial medical treatment in patients with NSTEACS, these agents do not reduce mortality although they slightly reduce the risk of death or MI.

This record should be cited as:

Bosch X, Marrugat J, Sanchis J. Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial medical treatment of non-ST segment elevation acute coronary syndromes. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD002130. DOI: 10.1002/14651858.CD002130.pub2

Assessed as up to date:

April 6, 2010

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Primary Review Group:

Heart Group

Health topics:

Heart & circulation > Myocardial ischemia/coronary disease > Acute coronary syndrome: antiplatelets

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial treatment of non-ST segment elevation acute coronary syndromes

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