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CLINICAL STUDY

Platelet glycoprotein IIb/IIIa blockade and outcome of cardiogenic shock complicating acute coronary syndromes without persistent ST-segment elevation

David Hasdai, MD^*, Robert A. Harrington, MD, FACC, Judith S. Hochman, MD, FACC, Robert M. Califf, MD, FACC, Alexander Battler, MD, FACC^*, James W. Box, MS, Maarten L. Simoons, MD, FACC, Jaap Deckers, MD, Eric J. Topol, MD, FACC^|| and David R. Holmes, Jr., MD, FACC^¶

^* Rabin Medical Center, Petah Tikva, Israel
Duke Clinical Research Institute, Durham, North Carolina, USA
Columbia University/St. Luke’s/Roosevelt Hospital, New York, New York, USA
Cardialysis, Rotterdam, The Netherlands
^|| Cleveland Clinic Foundation, Cleveland, Ohio, USA
^¶ Mayo Clinic and Foundation, Rochester, Minnesota, USA

Manuscript received November 1, 1999; revised manuscript received March 1, 2000, accepted April 12, 2000.

Reprint requests and correspondence: Dr. David R. Holmes, Jr., Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
dholmes{at}mayo.edu

OBJECTIVES

The study examined whether antiplatelet treatment with eptifibatide affected the frequency and outcome of shock among patients in the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial who had acute coronary syndromes but not persistent ST-segment elevation.

BACKGROUND

Preliminary reports suggest a salutary effect of antiplatelet agents when shock complicates acute myocardial infarction.

METHODS

We analyzed the impact of antiplatelet treatment with eptifibatide on the frequency and outcome of cardiogenic shock developing after enrollment. PURSUIT was a double-blind, randomized trial that examined the efficacy of eptifibatide (180 µg/kg bolus + continuous infusion of 2.0 µg/kg/min for 96 h) versus placebo among patients who had acute coronary syndromes but not persistent ST-segment elevation.

RESULTS

Shock developed in 2.5% of the 9,449 patients at a median (25th, 75th interquartiles) of 94.0 (38, 206) h. Death by 30 days occurred in 65.8% of shock patients. Patients who had acute myocardial infarction upon enrollment had a greater incidence of shock (2.9% vs. 2.1%, p = 0.01), developed shock earlier (40.2% <48 h vs. 20.9%, p = 0.001), and had higher 30-day mortality from shock (77.2% vs. 52.7%, p = 0.001). Randomization to eptifibatide did not affect the occurrence of shock (p = 0.71, adjusted odds ratio [OR] = 0.95, 95% confidence interval [CI] = 0.72–1.25). However, shock patients treated with eptifibatide had significantly reduced adjusted odds of 30-day death (p = 0.03, adjusted OR = 0.51, 95% CI = 0.28–0.94).

CONCLUSIONS

Patients with shock treated with eptifibatide had significantly reduced adjusted odds of death, suggesting a salutary effect of antiplatelet therapy on shock. This finding warrants verification in specifically designed studies.

Abbreviations and Acronyms   GUSTO I = Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries   GUSTO IIb = Global Use of Strategies to Open Occluded Coronary Arteries IIb   CK-MB = creatine kinase-myocardial band   PURSUIT = Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy

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