This Article Figures Only Full Text Full Text (PDF) All Versions of this Article: j.jacc.2005.11.012v1 47/3/522    most recent Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (33) Citing Articles via Google Scholar Google Scholar Articles by Bolognese, L. Articles by Burali, A. Search for Related Content PubMed PubMed Citation Articles by Bolognese, L. Articles by Burali, A. Related Collections Related Article

CLINICAL RESEARCH: PLATELET INHIBITION

Randomized Comparison of Upstream Tirofiban Versus Downstream High Bolus Dose Tirofiban or Abciximab on Tissue-Level Perfusion and Troponin Release in High-Risk Acute Coronary Syndromes Treated With Percutaneous Coronary Interventions

The EVEREST Trial

Azienda Ospedaliera Arezzo, Arezzo, Italy.

Manuscript received November 26, 2004; revised manuscript received January 26, 2005, accepted February 8, 2005.

^_* Reprint requests and correspondence: Dr. Leonardo Bolognese, Department of Cardiovascular Diseases, Azienda Ospedaliera Arezzo Via P. Nenni n. 22, 52100 Arezzo, Italy. (Email: leonardobolognese{at}hotmail.com).

OBJECTIVES: We aimed to compare the effects of upstream tirofiban versus downstream high-dose bolus (HDB) tirofiban and abciximab on tissue level perfusion and troponin I release in high-risk non–ST-segment elevation acute coronary syndrome (ACS) patients treated with percutaneous coronary intervention (PCI).

BACKGROUND: Optimal timing and dosage of glycoprotein IIb/IIIa inhibitors for ACS remain to be explored.

METHODS: We randomized 93 high-risk ACS patients undergoing PCI to receive upstream (in the coronary care unit) tirofiban, downstream (just prior to PCI) HDB tirofiban, and downstream abciximab. We evaluated the effects of the three drug regimens on tissue-level perfusion using the corrected Thrombolysis In Myocardial Infarction (TIMI) frame count, the TIMI myocardial perfusion grade (TMPG), and intracoronary myocardial contrast echocardiography (MCE) before and immediately after PCI and after cardiac troponin I (cTnI).

RESULTS: The TMPG 0/1 perfusion was significantly less frequent with upstream tirofiban compared with HDB tirofiban and abciximab both before (28.1% vs. 66.7% vs. 71%, respectively; p = 0.0009) and after PCI (6.2% vs. 20% vs. 35.5%, respectively; p = 0.015). Upstream tirofiban was also associated with a significantly higher MCE score index (0.88 ± 0.18 vs. 0.77 ± 0.32 vs. 0.71 ± 0.30, respectively; p < 0.05). Post-procedural cTnI elevation was significantly less frequent among patients in the upstream tirofiban group compared with the HDB tirofiban and abciximab groups (9.4% vs. 30% vs. 38.7%, respectively; p = 0.018). The cTnI levels after PCI were significantly lower with upstream tirofiban compared with HDB tirofiban (3.8 ± 4.1 vs. 7.2 ± 12; p = 0.015) and abciximab (3.8 ± 4.1 vs. 9 ± 13.8; p = 0.0002)

CONCLUSIONS: Among high-risk non–ST-segment-elevation ACS patients treated with an early invasive strategy, upstream tirofiban is associated with improved tissue-level perfusion and attenuated myocardial damage.

Abbreviations and Acronyms   ACS = acute coronary syndrome   CAD = coronary artery disease   CCU = coronary care unit   cTFC = corrected TIMI frame count   cTnI = cardiac troponin I   GP = glycoprotein   HDB = high-dose bolus   MCE = myocardial contrast echocardiography   NSTE-ACS = non–ST-segment-elevation acute coronary syndrome   PCI = percutaneous coronary intervention   TACTICS-TIMI 18 = Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction 18   TIMI = Thrombolysis In Myocardial Infarction   TMPG = TIMI myocardial perfusion grade

Related Article

Upstream/Downstream: Glycoprotein IIb/IIIa in Non–ST-Segment Elevation Myocardial Infarction

Ori Ben-Yehuda
J. Am. Coll. Cardiol. 2006 47: 538-540. [Full Text] [PDF]

This article has been cited by other articles:

				P. Tricoci, L. K. Newby, V. Hasselblad, D. F. Kong, R. P. Giugliano, H. D. White, P. Theroux, G. W. Stone, D. J. Moliterno, F. Van de Werf, et al. Upstream Use of Small-Molecule Glycoprotein IIb/IIIa Inhibitors in Patients With Non-ST-Segment Elevation Acute Coronary Syndromes: A Systematic Overview of Randomized Clinical Trials Circ Cardiovasc Qual Outcomes, July 1, 2011; 4(4): 448 - 458. [Abstract] [Full Text] [PDF]

				R. E. O'Connor, L. Bossaert, H.-R. Arntz, S. C. Brooks, D. Diercks, G. Feitosa-Filho, J. P. Nolan, T. L. V. Hoek, D. L. Walters, A. Wong, et al. Part 9: Acute Coronary Syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation, October 19, 2010; 122(16_suppl_2): S422 - S465. [Full Text] [PDF]

				M. Valgimigli Balancing safety and efficacy: recent clinical evidence optimizing outcomes in patients with intermediate to high-risk non-ST-segment elevated acute coronary syndrome Eur. Heart J. Suppl., September 1, 2010; 12(suppl_D): D14 - D23. [Abstract] [Full Text] [PDF]

				M. Valgimigli, G. Biondi-Zoccai, M. Tebaldi, A. W.J. van 't Hof, G. Campo, C. Hamm, J. ten Berg, L. Bolognese, F. Saia, G. B. Danzi, et al. Tirofiban as adjunctive therapy for acute coronary syndromes and percutaneous coronary intervention: a meta-analysis of randomized trials Eur. Heart J., January 1, 2010; 31(1): 35 - 49. [Abstract] [Full Text] [PDF]

				M. P. Bonaca, P. G. Steg, L. J. Feldman, J. F. Canales, J. J. Ferguson, L. Wallentin, R. M. Califf, R. A. Harrington, and R. P. Giugliano Antithrombotics in Acute Coronary Syndromes J. Am. Coll. Cardiol., September 8, 2009; 54(11): 969 - 984. [Abstract] [Full Text] [PDF]

				C.-C. Fang, Yeun Tarl Fresner NgJao, Yi Chen, C.-L. Yu, and S.-P. Wang Glycoprotein IIb/IIIa Inhibitor (Tirofiban) in Acute ST-Segment Elevation Myocardial Infarction Angiology, April 1, 2009; 60(2): 192 - 200. [Abstract] [PDF]

				M. Valgimigli, G. Campo, G. Percoco, L. Bolognese, C. Vassanelli, S. Colangelo, N. de Cesare, A. E. Rodriguez, M. Ferrario, R. Moreno, et al. Comparison of Angioplasty With Infusion of Tirofiban or Abciximab and With Implantation of Sirolimus-Eluting or Uncoated Stents for Acute Myocardial Infarction: The MULTISTRATEGY Randomized Trial JAMA, April 16, 2008; 299(15): 1788 - 1799. [Abstract] [Full Text] [PDF]

				S. R. Dixon, C. L. Grines, and W. W. O'Neill The Year in Interventional Cardiology J. Am. Coll. Cardiol., July 17, 2007; 50(3): 270 - 285. [Full Text] [PDF]

				D. Dudek, A. Dziewierz, B. Chyrchel, L. Polonski, J. Legutko, and J. S. Dubiel Antiplatelet treatment in non-ST-segment elevation acute coronary syndrome patients undergoing percutaneous coronary intervention (ISAR-REACT 2 insight) Eur. Heart J. Suppl., February 1, 2007; 9(suppl_A): A25 - A31. [Abstract] [Full Text] [PDF]

				D. J. Kereiakes and E. M. Antman Clinical Guidelines and Practice: In Search of the Truth J. Am. Coll. Cardiol., September 19, 2006; 48(6): 1129 - 1135. [Abstract] [Full Text] [PDF]

				R. P. Giugliano and E. Braunwald The Year in Non-ST-Segment Elevation Acute Coronary Syndromes J. Am. Coll. Cardiol., July 18, 2006; 48(2): 386 - 395. [Full Text] [PDF]

				Upstream vs. Downstream GPIIb/IIIa Inhibition in ACS Journal Watch Cardiology, March 16, 2006; 2006(316): 3 - 3. [Full Text]