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Small molecule glycoprotein IIb/IIIa receptor inhibitors as upstream therapy in acute coronary syndromes

Insights from the TACTICS TIMI-18 trial

^* TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA

Manuscript received May 7, 2002; accepted December 18, 2002.

^* Reprint requests and correspondence: Dr. Christopher P. Cannon, TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115, USA.
cpcannon{at}partners.org

Glycoprotein (GP) IIb/IIIa inhibitors are beneficial in unstable angina/non–ST-segment elevation myocardial infarction (UA/NSTEMI). In large trials, the GP IIb/IIIa inhibitors tirofiban and eptifibatide were each found to reduce the risk of death or myocardial infarction (MI) in these patients at 30 days. These agents appear to be of greatest benefit in patients with a positive troponin at baseline, diabetes or ST-segment depression, recurrent angina, prior aspirin use, or a Thrombolysis In Myocardial Infarction (TIMI) risk score 4. The Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy (TACTICS) TIMI-18 trial was designed to compare the benefits of an early invasive versus a conservative strategy in high-risk UA/NSTEMI patients treated with GP IIb/IIIa inhibition. Patients were treated with tirofiban (for 48 h) plus aspirin and heparin and randomized to either invasive therapy (coronary angiography and revascularization when feasible) or conservative treatment (angiography only for patients with recurrent ischemia at rest or a positive stress test). A significant reduction in death or MI was demonstrated at 30 days (p = 0.02) and at 6 months (p = 0.0498). Death, MI, or rehospitalization for an acute coronary syndrome was also reduced with the invasive therapy at six months (p = 0.025). These results provide evidence to physicians that early GP IIb/IIIa inhibition in combination with a prompt invasive approach should be used more widely in UA/NSTEMI patients, particularly those at high risk.

Abbreviations and Acronyms   CABG = coronary artery bypass graft   GP = glycoprotein   MI = myocardial infarction   NSTE = non–ST-segment elevation   PCI = percutaneous coronary intervention   UA = unstable angina

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