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ACC/AHA UA/NSTEMI Guidelines:
Role of GP IIb/IIIa Inhibitors
VBWG
ACC/AHA guidelines for UA/NSTEMI:
GP IIb/IIIa inhibitors
I IIa IIb III
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. 2002;40:1366-74.
VBWG
ACC/AHA UA/NSTEMI Guidelines:
Management of high-risk patients
High-risk patients
• Signs of ischemia at rest >20 minutes AND ST-segment
depression and/or elevated cardiac biomarkers
Immediate treatment (Class Ia)
• ASA or clopidogrel if ASA contraindicated
• LMWH or UFH
• GP IIb/IIIa inhibitor
Diagnostic catheterization and revascularization
within 24–48 hours (Class Ia)
Adapted from Braunwald E et al. J Am Coll Cardiol. 2002;40;1366-74.
VBWG
Mortality risk is lower with early
(<24-hour) GP IIb/IIIa inhibition
Favors
early GP IIb/IIIa
inhibitor
Favors
no early GP IIb/IIIa
inhibitor
Adjusted OR (95% Cl)
6 RCTs ACS
(N = 31,402)
0.91 (0.81–1.02)
CRUSADE ACS
(N = 49,378)
0.93 (0.83–1.05)
CRUSADE Tn+
(n = 32,290)
0.88 (0.77–1.01)
NRMI NSTEMI
(n = 60,770)
0.88 (0.79–0.97)
0.5
1.0
2.0
Odds ratio
RCT = randomized control trial
Tn+ = troponin positive
Boersma E et al. Lancet. 2002;359:189-98.
Hoekstra JW et al. Acad Emerg Med. 2005;12:431-8.
VBWG
Recommended therapies for UA/NSTEMI
Acute therapies (<24h)
Discharge therapies
• Aspirin
• Aspirin
• -Blocker
• Clopidogrel
• Heparin (UFH or LMWH)
• -Blocker
• GP IIb/IIIa inhibitor
(all receiving PCI/cath)
• ACE inhibitor
• Clopidogrel (all receiving PCI)
• Catheterization/
revascularization ≤48 hours
• Statin/lipid lowering
• Smoking cessation
• Cardiac rehabilitation
Braunwald E et al. J Am Coll Cardiol. 2002;40:1355-74.
VBWG
Majority of ACS patients undergo catheterization
CRUSADE registry data: October 1, 2004–September 30, 2005 (n = 35,897)
100
82
80
63
Patients
(%)*
60
52
40
40
20
12
0
Cath
Cath
<48 hr
*Without contraindication to catheterization
PCI
PCI
<48 hr
CABG
CRUSADE. www.crusadeqi.com