Drug therapy during percutaneous coronary interventions in stable and unstable coronary artery disease: the Italian Drug Evaluation in Angioplasty (IDEA) study.
BACKGROUND
Although periprocedural drug therapy has been shown to improve the outcome of percutaneous coronary intervention (PCI), information regarding its use in daily clinical practice is limited.


METHODS
We conducted a national survey on periprocedural drug therapy across the spectrum of PCI practice in Italy. Seventy-nine centers (41% of the Italian interventional cath labs) with a fair distribution across the country volunteered to enroll consecutive patients undergoing PCI for any indication from September 15 to 29, 2003.


RESULTS
Of the 1517 patients enrolled, 745 (49 %) had stable coronary disease and 772 (51%) acute coronary syndromes (ACS): 457 without and 315 with ST-segment elevation. Stenting was used in 89% of cases. N-acetylcysteine was used in 23% of the patients with preexisting renal dysfunction. Thienopyridine (63% clopidogrel) pretreatment was given in 49 % of the cases and, at logistic regression analysis, was independently associated with prior myocardial infarction (p < 0.001), prior PCI (p = 0.007), stable coronary disease (p = 0.005), and treatment in northern Italy (p < 0.05). Platelet glycoprotein (GP) IIb/IIIa receptor blockers (50% abciximab 50% tirofiban) were used in 22% of the stable patients and 40 % of those with ACS, a proportion increasing to 62 % when PCI was undertaken as an emergency procedure. Off-label use of these drugs was frequent (direct cath lab use of tirofiban in 55% of the cases; bailout use: 16% with abciximab and 26% with tirofiban). At logistic regression analysis, independent predictors of GP IIb/IIIa receptor blocker use were emergency procedure (odds ratio 3.6, 95 % confidence interval 2.6 to 5.0, p < 0.0001) and treatment for an ACS (odds ratio 1.6, 95% confidence interval 1.3 to 2.1, p = 0.0002). An emergency procedure was the only independent predictor for the use of abciximab instead of tirofiban (odds ratio 4.1, 95% confidence interval 2.6 to 6.5, p < 0.0001). Triple periprocedural antiplatelet therapy, including aspirin, a thienopyridine and a GP IIb/IIIa receptor blocker was administered in only 21% of cases. At discharge, all stented patients received aspirin and a thienopyridine. Despite complete procedural success in > 90% of cases, 50% of the patients were discharged on symptomatic anti-ischemic therapy.


CONCLUSIONS
A wide gap exists between guideline recommendations and periprocedural drug therapy in PCI, the only exception being full prescription of aspirin and a thienopyridine at discharge after stenting. In patients with ACS, thienopyridine pretreatment is often used as a surrogate for GP IIb/IIIa blockade, whose use rather is associated with emergency procedures. Off-label use of drugs is not uncommon.
Savonitto
Stefano
S
"A De Gasperis" Cardiothoracic Department, Niguarda Ca' Granda Hospital, Milan, Italy. stefano.savonitto@fastwebnet.it
Ambrosini
Vittorio
V
Marzocchi
Antonio
A
Tolaro
Salvatore
S
Petronio
Anna Sonia
AS
Galassi
Alfredo R
AR
Bongo
Angelo Sante
AS
Gaglione
Antonio
A
Bolognese
Leonardo
L
D000111:Acetylcysteine / Q000627:therapeutic use; D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000592:standards*; D000925:Anticoagulants / Q000627:therapeutic use*; D001241:Aspirin / Q000627:therapeutic use; D000077144:Clopidogrel; D003324:Coronary Artery Disease / Q000188:drug therapy* / Q000628:therapy; D017723:Drug Utilization Review; D005260:Female; D019538:Health Care Surveys; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D017410:Practice Guidelines as Topic; D011725:Pyridines / Q000627:therapeutic use; D012042:Registries; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000627:therapeutic use
D000319:Adrenergic beta-Antagonists; D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D011725:Pyridines; C446540:thienopyridine; D006493:Heparin; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin; D000111:Acetylcysteine