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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

View larger version (18K): [in a new window]   Figure 1 PRISM-PLUS: 30-day death/MI by strategy. Benefit of upstream tirofiban stratified by the ultimate treatment strategy employed. CI = confidence interval; CABG = coronary artery bypass graft; MI = myocardial infarction; PRISM-PLUS = the Platelet Receptor inhibition for ISchemic Management in Patients Limited to very Unstable Signs and Symptoms; PTCA = percutaneous transluminal coronary angioplasty; Rx = treatment. Data from Barr E, Thornton AR, Sax FL, Snapinn SM, Theroux P. Benefit of tirofiban + heparin therapy in unstable angina/non–Q-wave myocardial infarction patients is observed regardless of interventional treatment. Circulation 1998;98 Suppl I:I504. Reprinted with permission from Lippincott, Williams and Wilkins.

View larger version (19K): [in a new window]   Figure 2 Level of platelet inhibition achieved after a 12-h bolus and infusion of abciximab. RPFA = rapid platelet function assay. Reprinted with permission from Lippincott, Williams and Wilkins. Steinhubl SR, Kottke-Marchant K, Moliterno DJ, et al. Attainment and maintenance of platelet inhibition by standard dosing of abciximab in diabetic and nondiabetic patients undergoing percutaneous coronary intervention. Circulation 1999;100:1977–82.

View larger version (19K): [in a new window]   Figure 3 Benefit of glycoprotein IIb/IIIa inhibition in UA/NSTEMI based on positive or negative troponin levels. CAPTURE = c7E3 AntiPlatelet Therapy in Unstable REfractory angina to standard treatment; PRISM = Platelet Receptor inhibition for ISchemic Management; TnI = troponin I; TnT = troponin T. Data from Hamm CW, Heeschen C, Goldmann B, et al. Benefit of abciximab in patients with refractory unstable angina in relation to serum troponin T levels. N Engl J Med 1999;340:1623–9. Data from Heeschen C, Hamm CW, Goldmann B, et al. Troponin concentrations for stratification of patients with acute coronary syndromes in relation to therapeutic efficacy of tirofiban. Lancet 1999;354:1757–62. Reprinted with permission from Elsevier Science.

View larger version (22K): [in a new window]   Figure 4 Preliminary results from the Percutaneous Coronary Intervention-Treat Angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy (PCI-TACTICS) substudy. Longer duration of tirofiban was associated with improvements in myocardial perfusion grade coronary flow and coronary thrombus grade. MV = multivariate; TIMI = Thrombolysis In Myocardial Infarction; TnT = troponin T. Reprinted with permission from Lippincott, Williams and Wilkins. Data from Gibson M, Murphy SA, Weisberg S, et al. Early initiation of tirofiban therapy before percutaneous coronary intervention is associated with improved flow and tissue level perfusion: a TACTICS TIMI-18 substudy. Circulation 2001;104 Suppl II:II548–9.

View larger version (15K): [in a new window]   Figure 5 Comparison of event rates in the Thrombolysis In Myocardial Infarction (TIMI) IIIB versus Treat Angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy (TACTICS)-TIMI 18 trials stratified by TIMI risk score (TRS). ACS = acute coronary syndromes; CONS = conservative; Intermed = intermediate; INV = invasive; MI = myocardial infarction; Rehosp = rehospitalization. Reprinted with permission from Lippincott, Williams and Wilkins. Data from Sabatine MS, Cannon CP, Murphy SA, DiBattiste PM, Demopoulos LA, Braunwald E. Implications of upstream GP IIb/IIIa inhibition and stenting in the invasive management of UA/NSTEMI: a comparison of TIMI IIIB and TACTICS TIMI-18. Circulation 2001;104 Suppl II:II549.