Emergency coronary artery bypass grafting in patients with acute myocardial infarction treated with glycoprotein IIb/IIIa receptor inhibitors.
Glycoprotein (GP) IIb/IIIa receptor inhibitors before primary angioplasty in patients with ST-elevation acute myocardial infarction (STEMI) are recommended by current guidelines. Thus, an increasing number of patients receive these drugs before coronary angiography, particularly if a between-hospital transfer is needed. However, when coronary anatomy is unsuitable for angioplasty, emergency coronary artery bypass grafting (CABG) under GP IIb/IIIa inhibitor treatment may be needed, with a potential increase in bleeding risk. Abciximab has a long duration of action, because of its high-affinity binding to GP IIb/IIIa receptors. Initial retrospective studies reported a higher incidence of major bleeding during emergency CABG after abciximab administration, leading to the recommendation of delaying surgery >12 h. However, data from the prospective trials on abciximab do not confirm the increase in bleeding risk, and current evidence shows that emergency surgery can be performed safely soon after abciximab cessation. Monitoring of activated clotting time during surgery and platelet transfusion in case of postoperative relevant bleeding are the only measures needed. No data are available on emergency surgery in patients with STEMI treated with eptifibatide or tirofiban. However, their short-lasting effects and the results of trials on non-ST-elevation acute coronary syndromes suggest that they could even reduce postoperative bleeding by preventing platelet consumption during cardiopulmonary bypass. In conclusion, the early administration of GP IIb/IIIa inhibitors, in particular of abciximab, in patients with STEMI in whom primary angioplasty is planned should not be discouraged because of the potential bleeding risk in case of emergency CABG.
De Carlo
Marco
M
Cardiology Unit, Cardiothoracic Department, University of Pisa, Italy. marcodecarlo@gmail.com
Maselli
Daniele
D
Cortese
Bernardo
B
Ciabatti
Nicola
N
Gistri
Roberto
R
Levantino
Maurizio
M
Balbarini
Alberto
A
De Caterina
Raffaele
R
Petronio
Anna Sonia
AS
D000077284:Abciximab; D000911:Antibodies, Monoclonal / Q000008:administration & dosage; D003131:Combined Modality Therapy; D001026:Coronary Artery Bypass / Q000379:methods*; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D004638:Emergency Treatment; D000077542:Eptifibatide; D005260:Female; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000008:administration & dosage; D007262:Infusions, Intravenous; D008297:Male; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D010455:Peptides / Q000008:administration & dosage; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D011379:Prognosis; D016019:Survival Analysis; D000077466:Tirofiban; D016896:Treatment Outcome; D014443:Tyrosine / Q000008:administration & dosage / Q000031:analogs & derivatives
D000911:Antibodies, Monoclonal; D007140:Immunoglobulin Fab Fragments; D010455:Peptides; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D014443:Tyrosine; D000077466:Tirofiban; D000077542:Eptifibatide; D000077284:Abciximab