title: Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials.
abstract: BACKGROUND
  Platelet glycoprotein IIb/IIIa inhibitors have been shown to reduce cardiac complications in patients undergoing percutaneous coronary intervention. The clinical efficacy of these drugs in acute coronary syndromes, however, is still unclear. We did a meta-analysis of all large randomised trials designed to study the clinical efficacy and safety of glycoprotein IIb/IIIa inhibitors in patients with acute coronary syndromes who were not routinely scheduled to undergo early coronary revascularisation.
  
  
  METHODS
  Inclusion criteria were: randomisation of patients with acute coronary syndromes but without persistent ST elevation; comparison of a glycoprotein IIb/IIIa inhibitor with placebo or control therapy; non-recommendation of early coronary revascularisation during study-drug infusion; and enrollment of at least 1000 patients. Data on individual patients were obtained from all participants in these trials.
  
  
  RESULTS
  Six trials, enrolling 31402 patients, fulfilled the inclusion criteria. 30 days after randomisation, 3530 (11.2%) patients died or developed a myocardial infarction. At 30 days, a 9% reduction in the odds of death or myocardial infarction was seen with glycoprotein IIb/IIIa inhibitors compared with placebo or control (10.8% [1980/18297] vs 11.8% [1550/13105] events; odds ratio 0.91 [95% CI 0.84-0.98]; p=0.015). The relative treatment benefit was similar in subgroups of patients according to important clinical baseline characteristics; hence, the absolute treatment benefit was largest in high-risk patients. An unexpected and significant interaction was seen between sex and allocated treatment, with a treatment benefit in men (0.81 [0.75-0.89] but not in women (1.15 [1.01-1.30]). However, once patients were stratified according to troponin concentration, there was no evidence of a sex difference in treatment response, and a risk reduction was seen in men and women with raised troponin concentrations. Major bleeding complications were increased by glycoprotein IIb/IIIa inhibitors (2.4% [445/18297] vs 1.4% [180/13105]; p<0.0001), but intracranial bleeding was not (16 [0.09%] vs 8 [0.06%]; p=0.40).
  
  
  CONCLUSIONS
  Glycoprotein IIb/IIIa inhibitors reduce the occurrence of death or myocardial infarction in patients with acute coronary syndromes not routinely scheduled for early revascularisation. The event reduction is greatest in patients at high risk of thrombotic complications. Treatment with a glycoprotein IIb/IIIa inhibitor might therefore be considered especially in such patients early after admission, and continued until a decision about early coronary revascularisation has been made.
authors.affiliation: University Hospital Rotterdam, Rotterdam, The Netherlands. boersma@thch.azr.nl
authors.forename: Eric
authors.initials: E
authors.lastname: Boersma
authors.forename: Robert A
authors.initials: RA
authors.lastname: Harrington
authors.forename: David J
authors.initials: DJ
authors.lastname: Moliterno
authors.forename: Harvey
authors.initials: H
authors.lastname: White
authors.forename: Pierre
authors.initials: P
authors.lastname: Théroux
authors.forename: Frans
authors.initials: F
authors.lastname: Van de Werf
authors.forename: Anneke
authors.initials: A
authors.lastname: de Torbal
authors.forename: Paul W
authors.initials: PW
authors.lastname: Armstrong
authors.forename: Lars C
authors.initials: LC
authors.lastname: Wallentin
authors.forename: Robert G
authors.initials: RG
authors.lastname: Wilcox
authors.forename: John
authors.initials: J
authors.lastname: Simes
authors.forename: Robert M
authors.initials: RM
authors.lastname: Califf
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Topol
authors.forename: Maarten L
authors.initials: ML
authors.lastname: Simoons
mesh_terms: D000368:Aged; D000789:Angina, Unstable / Q000188:drug therapy*; D015906:Angioplasty, Balloon, Coronary; D001026:Coronary Artery Bypass; D023381:Endpoint Determination; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality / Q000628:therapy; D016017:Odds Ratio; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D016016:Proportional Hazards Models; D016032:Randomized Controlled Trials as Topic; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D019039:Platelet Glycoprotein GPIIb-IIIa Complex