title: A comparison between upfront high-dose tirofiban versus provisional use in the real-world of non-selected STEMI patients undergoing primary PCI: Insights from the Zwolle acute myocardial infarction registry.
abstract: BACKGROUND
  Despite the proven benefit of glycoprotein IIb/IIIa blockers in patients with acute ST-segment elevation myocardial infarction (STEMI), there is still debate on the timing of administration of these drugs and whether all or only a selection of patients should be treated. We evaluated the effect of routine upfront versus provisional use of high-dose tirofiban (HDT) in a large real-world population of non-selected STEMI patients.
  
  
  METHODS
  Consecutive STEMI patients were registered in a single-centre dedicated database. Patients with upfront HDT therapy before first balloon inflation were compared with patients who received the drug on a provisional basis, after first balloon inflation. Initial TIMI flow of the infarct-related vessel and enzymatic infarct size and 30-day clinical outcome were assessed.
  
  
  RESULTS
  Out of 2679 primary PCI patients HDT was given upfront in 885 (33.0%) and provisionally in 812 (45.3%). Upfront as compared with provisional HDT showed higher initial patency (22.3 vs. 17.9%, p=0.006), smaller infarct size (1401 IU/l (IQR 609 to 2948) vs. 1620 (753 to 3132), p=0.03) and a lower incidence of death or recurrent MI at 30 days (3.3 vs. 5.1%, p=0.04) without an increase in TIMI bleeding (p=0.24). Upfront HDT independently predicted initial patency (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.15 to 1.88, p=0.02), enzymatic infarct size (OR 0.70, 95% CI 0.56 to 0.86, p=0.001) and 30-day death or recurrent MI (OR 0.59, 95% CI 0.37 to 0.95, p=0.03).
  
  
  CONCLUSIONS
  Our findings support the use of upfront potent antiplatelet and antithrombotic therapy in STEMI patients and encourage further clinical investigations in this field. (Neth Heart J 2010;18:592-7.).
authors.affiliation: Department of Cardiology, Medical Centre Alkmaar, Alkmaar, the Netherlands.
authors.forename: A A C M
authors.initials: AA
authors.lastname: Heestermans
authors.forename: R S
authors.initials: RS
authors.lastname: Hermanides
authors.forename: A T M
authors.initials: AT
authors.lastname: Gosselink
authors.forename: M J
authors.initials: MJ
authors.lastname: de Boer
authors.forename: J C A
authors.initials: JC
authors.lastname: Hoorntje
authors.forename: H
authors.initials: H
authors.lastname: Suryapranata
authors.forename: J P
authors.initials: JP
authors.lastname: Ottervanger
authors.forename: J-H E
authors.initials: JH
authors.lastname: Dambrink
authors.forename: E
authors.initials: E
authors.lastname: Kolkman
authors.forename: J M
authors.initials: JM
authors.lastname: Ten Berg
authors.forename: F
authors.initials: F
authors.lastname: Zijlstra
authors.forename: A W J
authors.initials: AW
authors.lastname: van 't Hof