Platelet glycoprotein IIb/IIIa blockers for percutaneous coronary revascularization, and unstable angina and non-ST-segment elevation myocardial infarction.
BACKGROUND
During percutaneous coronary revascularisation (i.e. coronary angioplasty (PTCA) with or without stent implantation), and in unstable angina/non-ST-segment elevation myocardial infarction, the risk of acute vessel occlusion by thrombosis is high in spite of treatment with aspirin and heparin. GP IIb/IIIa antagonists inhibit platelet aggregation and may prevent mortality and myocardial infarction.


OBJECTIVE
To assess the efficacy and safety of GP IIb/IIIa blockers during percutaneous coronary revascularisation, and in patients with unstable angina/non-ST-segment elevation myocardial infarction.


METHODS
We searched the Cochrane Library (issue 1, 2000), MEDLINE (1966 to June 2001), EMBASE (1980 to Nov 1999), reference list of articles, medical websites and handsearch among abstracts from cardiology congresses.


METHODS
Randomized controlled trials comparing intravenous GP IIb/IIIa blockers with standard medical treatment during percutaneous coronary revascularisation, and in patients with unstable angina/non-ST-segment elevation myocardial infarction.


METHODS
A list of titles and abstracts was screened separately by two reviewers who assessed trial quality and extracted data.


RESULTS
Percutaneous coronary revascularisation: Fourteen trials involving 17,788 patients were included. GP IIb/IIIa blockers were associated with decreased mortality at 30 days (OR 0.71 (95% CI 0.52, 0.97)) but not at 6 months (OR 0.85 (0.66, 1.11)). Mortality or infarction was decreased both at 30 days (OR 0.62 (0.55, 0.70); ARR: 31 per 1,000), and at 6 months (OR 0.65 (0.58, 0.73); ARR: 38 per 1,000)), but severe bleeding was increased (10 per 1,000; OR 1.38 (1.04, 1.85)). Unstable angina/non-ST-segment elevation myocardial infarction: Eight trials involving 30,006 patients were included. GP IIb/IIIa blockers were not associated with decreased mortality at 30 days (OR 0.90 (0.80, 1.02)) or at 6 months (OR: 1.01 (0.88, 1.16)). Mortality or infarction was decreased at 30 days (OR 0.91 (0.85, 0.98); ARR: 13 per 1,000)) and at 6 months (OR 0,88 (0.81, 0.95); ARR: 13 per 1,000)), although severe bleeding was increased (1 per 1,000; OR 1.27 (1.12, 1.44)).


CONCLUSIONS
Intravenous GP IIb/IIIa blockers reduce the risk of death at 30 days and markedly that of death or MI at 30 days and 6 months in patients submitted to percutaneous coronary revascularisation at a price of a moderate increased risk of severe bleeding. In contrast, in patients with unstable angina/non-ST-segment elevation myocardial infarction, these agents do not reduce mortality, only slightly reduce the risk of death or MI, and slightly increase the risk for severe bleeding.
Bosch
X
X
Institute de Malaties Cardiovasculars, University of Barcelona, Hospital Clinic, Villarroel, 170, Barcelona, Spain, E-08036. xbosch@medicina.ub.es
Marrugat
J
J
D000789:Angina, Unstable / Q000150:complications; D015906:Angioplasty, Balloon, Coronary / Q000379:methods*; D001241:Aspirin / Q000627:therapeutic use; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D009203:Myocardial Infarction / Q000188:drug therapy / Q000401:mortality / Q000517:prevention & control*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D013988:Ticlopidine / Q000627:therapeutic use
D005343:Fibrinolytic Agents; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D006493:Heparin; D013988:Ticlopidine; D001241:Aspirin