Early glycoprotein IIb‐IIIa inhibitors in primary angioplasty‐abciximab long‐term results (EGYPT‐ALT) cooperation: individual patient’s data meta‐analysis

Summary. Background: Even although time to treatment has been shown to be a determinant of mortality in primary angioplasty, the potential benefits are still unclear from early pharmacological reperfusion by glycoprotein (Gp) IIb‐IIIa inhibitors. Therefore, the aim of this meta‐analysis was to combine individual data from all randomized trials conducted on upstream as compared with late peri‐procedural abciximab administration in primary angioplasty. Methods: The literature was scanned using formal searches of electronic databases (MEDLINE and EMBASE) from January 1990 to December 2010. All randomized trials on upstream abciximab administration in primary angioplasty were examined. No language restrictions were enforced. Results: We included a total of seven randomized trials enrolling 722 patients, who were randomized to early (n = 357, 49.4%) or late (n = 365, 50.6%) peri‐procedural abciximab administration. No difference in baseline characteristics was observed between the two groups. Follow‐up data were collected at a median (25th–75th percentiles) of 1095 days (720–1967). Early abciximab was associated with a significant reduction in mortality (primary endpoint) [20% vs. 24.6%; hazard ratio (HR) 95% confidence interval (CI) = 0.65 (0.42–0.98) P = 0.02, P_het = 0.6]. Furthermore, early abciximab administration was associated with a significant improvement in pre‐procedural thrombolysis in myocardial infarction (TIMI) 3 flow (21.6% vs. 10.1%, P < 0.0001), post‐procedural TIMI 3 flow (90% vs. 84.8%, P = 0.04), an improvement in myocardial perfusion as evaluated by post‐procedural myocardial blush grade (MBG) 3 (52.0% vs. 43.2%, P = 0.03) and ST‐segment resolution (58.4% vs. 43.5%, P < 0.0001) and significantly less distal embolization (10.1% vs. 16.2%, P = 0.02). No difference was observed in terms of major bleeding complications between early and late abciximab administration (3.3% vs. 2.3%, P = 0.4). Conclusions: This meta‐analysis shows that early upstream administration of abciximab in patients undergoing primary angioplasty for ST‐segment elevation myocardial infarction (STEMI) is associated with significant benefits in terms of pre‐procedural epicardial re‐canalization and ST‐segment resolution, which translates in to significant mortality benefits at long‐term follow‐up.     

Facilitated angioplasty with combo therapy among patients with ST-segment elevation myocardial infarction: a meta-analysis of randomized trials

Introduction

Time to treatment has been shown to be a major determinant of mortality in primary angioplasty. The aim of the current study was to perform a meta-analysis of randomized trials evaluating the benefits from pharmacologic facilitation with adjunctive glycoprotein (Gp) IIb-IIIa inhibitors + reduced lytic therapy vs adjunctive Gp IIb-IIIa inhibitors among patients with ST-segment elevation myocardial infarction (MI).

Methods

We obtained results from all randomized trials comparing facilitated PCI with adjunctive Gp IIb-IIIa inhibitors and reduced lytic therapy vs adjunctive Gp IIb-IIIa inhibitors among patients with ST-segment elevation MI (STEMI). The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL) from January 1990 to December 2007. The following key words were used: randomized trial, MI, reperfusion, primary angioplasty, pharmacologic facilitation, facilitated angioplasty, combo therapy, fibrinolysis, thrombolysis, half-dose lytic therapy, duteplase, reteplase, tenecteplase, alteplase, abciximab, tirofiban, eptifibatide, and Gp IIb-IIIa inhibitors. Angiographic end points were the rate of preprocedural and postprocedural thrombolysis in MI (TIMI) 3 flow. Clinical end points assessed were mortality and reinfarction at 30-day follow-up, whereas major bleeding complications were assessed as safety end point. No language restriction was applied.

Results

We identified 6 randomized trials, including 2684 patients with STEMI. Even though combo therapy was associated with a significant improvement in preprocedural TIMI 3 flow (44.3% vs 15.2%, P < .0001, P_het < .0001), it did not improve the rate of postprocedural TIMI 3 flow (91.5% vs 91.2%, P = .12). No benefits were observed in terms of 30-day mortality (4.2% vs 4.6%, P = .66, P_het = .22) and/or 30-day reinfarction (1.3% vs 1.3%, P = .84). However, combo therapy was associated with higher risk of major bleeding complications (5.8% vs 3.9%, P = .03).

Conclusions

This meta-analysis shows that among patients with STEMI undergoing primary angioplasty, pharmacologic facilitation with combined reduced-dose thrombolytic therapy and Gp IIbIIIa inhibitors is not superior to Gp IIb-IIIa inhibitors alone and, thus, may not be routinely recommended. However, future randomized trials should investigate whether this strategy may further improve outcome when applied within the first hours from symptoms onset, especially in patients undergoing transferring for primary angioplasty.     

Percutaneous coronary intervention–related time delay,patient's risk profile,and survival benefits of primary angioplasty vs lytic therapy in ST-segment elevation myocardial infarction

Background

Previous reports have suggested an impact of patient's risk profile and percutaneous coronary intervention (PCI)–related time delay on the benefits of primary angioplasty as compared with fibrinolysis. However, several factors, such as inappropriate interpretation and definition of delays, missing currently available trials, and arguable risk-benefit analysis, limit the value of these reports. Thus, the aim of the current review is to assess whether the prognostic impact of PCI-related time delay may vary according to patient's risk profile, presentation delay, and type of lytic therapy.

Methods

We obtained results from all randomized trials comparing fibrinolysis and primary angioplasty in ST-segment elevation myocardial infarction. The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL) for papers published from January 1990 to April 2007. The following key words were used: randomized trial, myocardial infarction, reperfusion, primary angioplasty, rescue angioplasty, fibrinolysis, thrombolysis, duteplase, reteplase, tenecteplase, and alteplase. Major clinical end point assessed was mortality at 30-day follow-up. The relationship between mortality benefits from primary angioplasty, patient's risk profile, and PCI-related time delay was evaluated by using a weighted least-square regression in which results from each trial were weighted by the square root of the number of patients of each trial.

Results

A total of 27 trials were finally included, with 4399 patients randomized to primary angioplasty and 4474 patients randomized to fibrinolysis. The relationship between the benefits from primary angioplasty and PCI-related time changed according to risk profile. The higher the risk profile, the larger the reduction in mortality benefits from primary angioplasty as compared with fibrinolysis per each 10 minutes of PCI-related time delay (0.75%, 0.45%, and 0%, in high-, medium-, and low-risk patients, respectively). Furthermore, the impact was observed only in trials enrolling patients within the first 6 hours from symptom onset.

Conclusions

When primary angioplasty is selected as reperfusion strategy, all efforts should be attempted to shorten time-to-treatment, particularly in medium- or high-risk patients and in early presenters, because in these patients, a larger loss of mortality benefits as compared with fibrinolysis is observed per each 10 minutes of PCI-related time delay.     

Glycoprotein IIb/IIIa receptor inhibitors in percutaneous coronary intervention and acute coronary syndrome

OBJECTIVE: To review the contemporary role of the glycoprotein (GYP) IIb/IIIa receptor inhibitors abciximab, eptifibatide, and tirofiban in patients undergoing percutaneous coronary intervention (PCI) and those with an acute coronary syndrome (ACS), and to provide an algorithm based on currently available evidence for specific agents. DATA SOURCES: Primary articles were identified by a MEDLINE search (1966-January 2003); references cited in these articles provided additional resources. STUDY SELECTION AND DATA EXTRACTION: All of the articles identified from data sources were considered for relevant information; this article primarily addresses large, controlled or comparative studies, and meta-analyses. DATA SYNTHESIS: The role of GYP IIb/IIIa inhibitors in patients undergoing PCI and those with ACS has progressed markedly. To date, abciximab has the most robust data in patients undergoing PCI, particularly high-risk individuals. In PCI patients with lower risk (e.g., elective stenting), eptifibatide is a reasonable first-line option. Data do not support tirofiban for routine use in patients undergoing PCI. For individuals with signs and symptoms of ACS, specifically unstable angina or non-ST-segment elevation myocardial infarction (MI), eptifibatide or tirofiban is recommended in high-risk patients when a conservative approach is used (PCI is not planned). Abciximab is not recommended in this situation. In patients with ST-segment elevation MI (STEMI), abciximab is the only GYP IIb/IIIa inhibitor evaluated in large, well-designed investigations. For medical management in combination with a fibrinolytic agent, the role of abciximab remains unclear. For patients undergoing primary PCI for the management of STEMI, the available evidence supports the use of abciximab, albeit further investigation is warranted. CONCLUSIONS: The role of GYP IIb/IIIa inhibitors in clinical cardiology continues to evolve. Choice of the agent depends on situation of use, patient-specific characteristics and risk stratification, and, in the case of ACS, chosen management strategy (medical management or intervention).     

ST-elevation myocardial infarction: the role of adjunctive antiplatelet therapy

Antiplatelet therapy to reduce the risks of recurrent myocardial infarction and restenosis after primary percutaneous coronary intervention is critically important to optimize the early treatment of ST-segment elevation myocardial infarction (STEMI). Traditionally, acetylsalicylic acid (ASA; aspirin) has been recommended for patients with suspected STEMI, but this agent targets only one of several pathways of platelet aggregation. Antiplatelet agents with different inhibitory mechanisms may act synergistically with ASA. Glycoprotein IIb/IIIa inhibitors are generally not used with fibrinolytic agents in acute STEMI management; indeed, glycoprotein IIb/IIIa inhibitors plus bolus fibrinolytics increase the risk of intracranial hemorrhage. Aggressive antiplatelet therapy with clopidogrel reduces mortality in STEMI patients and offers significant clinical benefits, without an associated increase in major bleeding events. Recent trials support the development of an early and aggressive approach to more complete platelet inhibition using clopidogrel, in combination with ASA, for patients with STEMI.     

Endovascular stent implantation for treatment of peripheral artery disease

Endovascular stent implantation is a rapidly emerging technology for treatment of arterial obstructions in the entire circulation. During recent years, several randomized studies evaluated the effects of stenting in lower limb arteries. We herein provide an overview on data of trials in the iliac and femoropopliteal vessel area discussing the benefits and limitations of endovascular stents. In the iliac arteries, midterm and long-term data from one randomized trial including analysis on patency, clinical outcomes, cost-effectiveness and quality of life indicate that balloon angioplasty with selective stenting remains the therapy of choice for endovascular revascularization. In the femoropopliteal arteries, balloon-expanding stents were not superior to balloon angioplasty for treatment of short lesions, and self-expanding nitinol stents also failed to show a beneficial effect in short lesions below 5 cm. However, including longer lesions, one randomized trial indicated a beneficial effect of nitinol stents in lesions with a median length around 10-12 cm. Further studies and longer follow-up intervals are needed to confirm these data. Meanwhile, balloon angioplasty with optional stenting also remains the recommended endovascular approach for the femoropopliteal segment.     

Marked reduction of early stent thrombosis with pre-hospital initiation of high-dose Tirofiban in ST-segment elevation myocardial infarction

Summary.  Background : No randomized comparisons are yet available evaluating the effect of pre-hospital high dose tirofiban on the incidence of early stent thrombosis after primary percutaneous coronary intervention (PCI). Objectives : The aim of this analysis was to evaluate whether routine pre-hospital administration of high-dose tirofiban in ST-segment elevation myocardial infarction (STEMI) decreases the incidence of early stent thrombosis after primary PCI. Patients/methods : The Ongoing Tirofiban in Myocardial Evaluation (On-TIME) 2 trial was a prospective multicenter study of consecutive STEMI patients referred for primary PCI in which patients were randomized to pre-hospital no high-dose tirofiban/placebo. We examined the incidence of Academic Research Consortium definite and probable early stent thrombosis and determined predictors and outcome of early stent thrombosis. Results : Primary PCI was performed in 1203 out of 1398 patients (86.1%). In 1073 patients (89.2%) a coronary stent was placed. Early stent thrombosis occurred in 39 patients (3.6%). Pre-hospital initiation of high-dose tirofiban significantly reduced early stent thrombosis (2.1% vs. 5.2%, P  = 0.006) and was associated with a lower incidence of urgent repeat PCI (1.9% vs. 5.2%, P  = 0.005). Early stent thrombosis, as well as pre-hospital initiation of high-dose tirofiban, was independently associated with 30-day mortality. Conclusions : Pre-hospital initiation of high-dose tirofiban reduces the 30-day incidence of stent thrombosis in STEMI patients treated with primary PCI and stenting. Early stent thrombosis and pre-hospital initiation of high-dose tirofiban were independent predictors of 30-day mortality.     

Detecting failed thrombolysis in the accident and emergency department

The primary objective in managing a patient with ST segment elevation myocardial infarction (STEMI) is to establish reperfusion in the infarct-related artery and to maintain it. Two approaches to coronary reperfusion are used in the UK - primary angioplasty and intravenous thrombolysis. Primary angioplasty is the gold standard approach to managing STEMI, but in the UK (due to financial, resource and personnel limitations) this is not the first-line treatment. Thrombolytic therapy remains the most widely used approach and the benefits of such an approach are irrefutable; thrombolysis saves lives, reduces infarct size and limits left ventricular dysfunction. However, data from the thrombolytic trials also suggest that 30-40% of patients fail to reperfuse with standard thrombolytic therapy. Similar data demonstrates that patients who do not sustain adequate perfusion in the infarct-related artery have a poor prognosis and increased mortality rates. As long as thrombolysis remains the standard therapy for STEMI, it is important that patients in whom the treatment has been unsuccessful are swiftly recognised and appropriate interventions instituted. The criteria to assess successful reperfusion of the infarct-related artery need to be simple to apply, easy to interpret and non-invasive. This article will discuss the most useful criteria to make such a diagnosis and suggest approaches to enable recognition of 'failed thrombolysis' in the accident and emergency department. The current views on managing failed thrombolysis will conclude the article.     

Intracoronary versus intravenous bolus abciximab application in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: 6-month effects on infarct size and left ventricular function

Background

Administration of abciximab during primary percutaneous coronary intervention (PCI) reduces major adverse cardiac events (MACE) in patients with ST-elevation myocardial infarction (STEMI). Intracoronary (IC) abciximab bolus application during PCI results in high local drug concentration, improved perfusion, reduction of infarct size, and less microvascular obstruction early after infarction. Aim of this study was to investigate whether the early benefits of an IC abciximab administration in STEMI patients undergoing PCI are sustained at 6?months.

Methods

We performed 6-month follow-up of 154 STEMI patients undergoing PCI, who were randomised to either IC (n?=?77) or intravenous (IV) (n?=?77) bolus abciximab administration with subsequent 12-h intravenous infusion. The primary endpoint was infarct size at 6-month follow-up as assessed by delayed enhancement magnetic resonance imaging. Clinical end points were MACEs within 6?months after infarction.

Results

The median infarct size after 6?months was significantly reduced in the IC abciximab group (16.7 vs. 24.1%, p?=?0.002). A significant recovery of LV function was only observed in the IC abciximab group (p?<?0.001), and IC abciximab group patients had significantly less adverse remodelling as compared to standard IV abciximab treatment (p?=?0.03). These beneficial effects also translated into a strong trend towards a reduced MACE rate in the IC abciximab group at 6-month follow-up (10 vs. 21%, p?=?0.07).

Conclusions

Intracoronary abciximab application in STEMI patients undergoing PCI is superior to standard IV treatment with respect to infarct size, recovery of LV function and reverse remodelling 6?months after infarction.     

One-year clinical outcomes with abciximab in acute myocardial infarction: results of the BRAVE-3 randomized trial

Purpose

In the Bavarian Reperfusion Alternatives Evaluation (BRAVE)-3 study upstream administration of abciximab additional to 600 mg clopidogrel loading did not reduce the infarct size in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary interventions. The aim of this study was to investigate 1-year clinical outcomes in the BRAVE-3 study patients.

Methods

A total of 800 patients with acute STEMI within 24 h from symptom onset, all treated with 600 mg of clopidogrel were randomized in a double-blind fashion to receive either abciximab (n = 401) or placebo (n = 399) in the intensive care unit before being sent to the catheterization laboratory.

Results

The main outcome of interest of the present study, the composite of death, recurrent myocardial infarction, stroke or revascularization of the infarct-related artery (IRA) at 1 year, was 23.0% (92 patients) in the abciximab versus 25.7% (102 patients) in the placebo group [relative risk (RR) = 0.90, 95% confidence interval (CI) 0.67–1.20; P = 0.46]. The combined incidence of death, recurrent myocardial infarction or stroke was 9.3% in the abciximab group versus 6.0% in the placebo group (RR = 1.55, 95% CI 0.93–2.58; P = 0.09). There was a significant reduction of the IRA revascularization with abciximab compared to placebo (16.3 vs. 22.3%, RR = 0.71, 95% CI 0.52–0.98; P = 0.04).

Conclusion

In patients with STEMI, all receiving 600 mg clopidogrel, abciximab did not improve overall clinical outcomes at 1 year after primary coronary stenting.     

Cardiogenic shock: thrombolysis or angioplasty?

Cardiogenic shock (CGS) occurs in 3 to 20% of patients presenting with acute myocardial infarction (MI), and it generally involves dysfunction of at least 40% of the total myocardial mass. Prior to the advent of balloon angioplasty and thrombolysis, in-hospital mortality was greater than 75%. This mortality rate has been consistent in reported series despite the advent of cardiac intensive care units, vasopressor, inotropic, and vasodilator therapy. Intra-aortic balloon counterpulsation therapy provides hemodynamic improvement, and it may provide some mortality benefit when used in conjunction with appropriate revascularization. Survival studies have shown that patency of the infarct-related artery is a strong predictor of survival. No randomized trials have been completed to examine which reperfusion therapy best treats this emergent situation. Subgroup analysis of large scale, multicenter trials, although underpowered, has shown no improvement in mortality with use of thrombolytic agents, leading many to advise use of mechanical intervention. In patients who present with acute MI with contraindications to thrombolysis, primary angioplasty is the treatment of choice. At selected centers, primary angioplasty is comparable to or better than thrombolytic therapy for patients presenting with acute MI, with or without CGS. Studies examining angioplasty in patients with CGS have shown high procedural success rates (75%) and reduced in-hospital mortality (44%), particularly in those patients with successful revascularization. Emergency bypass surgery may improve survival, but it is costly, unavailable to many, and often leads to excessive delays in therapy. If available, we believe that primary angioplasty is the treatment of choice for patients with CGS.     

Prehospital treatment of patients with acute myocardial infarction with bivalirudin

Objectives

Patients with acute myocardial infarction are at high risk of dying within the first hours after onset of coronary ischemia. Therefore, pharmacological intervention should be started in the prehospital setting. This study investigates the effect of the prehospital administration of bivalirudin on short-term morbidity and mortality compared to heparin plus abciximab in patients with ST-segment-elevation myocardial infarction (STEMI).

Methods

One hundred ninety-eight patients with STEMI treated with bivalirudin in the prehospital setting were prospectively collected. Coronary angiography was performed to identify the infarct-related artery. In case of a percutaneous coronary intervention, bivalirudin was given according to the guidelines. The historic control group consisted of 171 consecutive patients from the same myocardial infarction network treated with unfractioned heparin and abciximab administration before the admission to the emergency department of the percutaneous coronary intervention center. The primary outcome parameter was the incidence of major adverse cardiac events (recurrent myocardial infarction, stroke, death, target vessel revascularization for ischemia) within 30 days after the primary event.

Results

The overall rate of major adverse cardiac events was significantly lower in the bivalirudin group compared to the abciximab group (7.6% vs 14.6%; P = .04). The number of major bleedings was significantly higher in the abciximab group compared to the bivalirudin group (11.8% vs 3.8%; P = .03).

Conclusions

The use of bivalirudin in the prehospital setting leads to a reduced rate of major cardiovascular events compared to a standard treatment with abciximab plus heparin. Bivalirudin is a reasonable choice of treatment in the prehospital setting for patients with STEMI.     

Update on management of acute myocardial infarction: facilitated percutaneous coronary intervention.

Combination therapy with abciximab and reteplase and heparin allows high rates of patency 60 minutes after therapy. PTCA is facilitated by these adjunctive therapies to improve procedural outcomes. Stent implantation and blockade of the platelet GP IIb/IIIa receptor with abciximab provide potent complementary benefits allowing PTCA to be performed at a new standard of safety and efficacy. Thus the acronym FPCI stands for the use of drugs, angioplasty and stenting. Time and experience will determine the efficacy of the combined pharmacological-mechanical bridge. We believe that FPCI is the wave of the future and that in skilled hands this emergent coordinated care of acute MI has lowered and will continue to lower morbidity and mortality in acute coronary events.     

The contemporary management of acute myocardial infarction.

The contemporary management of acute myocardial infarction continues to evolve rapidly. The ultimate goal of therapy is timely, complete, and sustained myocardial reperfusion. There is a powerful time-dependent effect on mortality, and thus the balance between the time and likelihood of maximal reperfusion is crucial in deciding whether to use primary percutaneous balloon angioplasty or thrombolysis as the initial reperfusion strategy. Newer thrombolytic agents allow for equivalent coronary reperfusion compared with the standard accelerated alteplase (tPA) regimen with the advantage of easier dosing regimens. Low molecular weight heparin has been shown to be superior to unfractionated heparin and likely will be the standard of care in the near future. The use of glycoprotein IIb/IIIa inhibitors has been shown to decrease the short- and long-term complication rates in patients with acute coronary syndromes treated medically and with percutaneous coronary interventions; however, the choice of the optimal agent and dosing regimen in various clinical settings remains controversial. Combination therapy with low-dose fibrinolytics, glycoprotein IIb/IIIa inhibitors, and low molecular weight heparin, with or without subsequent early planned percutaneous coronary interventions, may provide the optimal strategy for maximal coronary reperfusion, but the results of large, randomized mortality trials currently underway need to be analyzed. Risk stratification will continue to play a major role in determining which patients should receive a specific therapy. The care of the patient with an acute myocardial infarction will continue to be a challenge requiring the proper selection from the vast pharmaceutic and interventional options available.     

Hemorrhagic and vascular complications after percutaneous coronary intervention with adjunctive abciximab

OBJECTIVES: To examine the frequency and nature of hemorrhagic and peripheral vascular complications associated with use of abciximab during percutaneous coronary intervention and to characterize high-risk patients. PATIENTS AND METHODS: We report the frequency and severity of bleeding and vascular complications recorded prospectively in 2,559 consecutive nonselected patients who underwent percutaneous coronary intervention at Mayo Clinic, Rochester, Minn, between July 1, 1996, and April 30, 1998, 831 of whom received abciximab and 1,728 did not. Abciximab and heparin were administered according to guidelines of the Evaluation of PTCA [percutaneous transluminal coronary angioplasty] to Improve Long-Term Outcome With Abciximab GP IIb/IIIa Blockade (EPILOG). RESULTS: Patients who received abciximab were more likely to be men, were more often treated within 12 hours of an acute myocardial infarction, and were more likely to have received heparin after the procedure (8.7 % vs 4.5%, P<.001). Major bleeding occurred in 18 patients (2.4%) who received abciximab and in 10 patients (0.6%) who did not receive abciximab (P<.001). Minor bleeding occurred in 108 patients (14.3%) and in 92 patients (5.9%), respectively (P<.001). Both major bleeding and minor bleeding were more frequent among patients within 12 hours of an acute myocardial infarction and were more frequent if abciximab had been used. Multivariate analysis revealed that use of abciximab was independently associated with major and minor bleeding. CONCLUSION: In this clinical setting, use of adjunctive abciximab during percutaneous coronary intervention was associated with a significantly increased risk of both major and minor bleeding.     

Abciximab and atherosclerotic heart disease: use in percutaneous coronary intervention,acute coronary syndromes and acute myocardial infarction

Abciximab irreversibly binds to the glycoprotein IIb/IIIa receptor on both activated and unactivated platelets inhibiting platelet aggregation. It has been studied in a variety of clinical settings including percutaneous coronary intervention (PCI), ST-elevation myocardial infarction, and non ST-elevation acute coronary syndromes. Abciximab has been demonstrated to reduce acute ischaemic events in the setting of percutaneous intervention with both percutaneous transluminal coronary angioplasy and stenting. It has been shown to be particularly effective when used in patients with acute myocardial infarction undergoing primary PCI. The data for its effective use in the medical phase of therapy for patients with acute coronary syndromes, however, is not as consistent. In this article we review the major trials evaluating the use of abciximab in these clinical scenarios compared with placebo and alternative glycoprotein IIb/IIIa inhibitors.     

What is the latest in inventory for carotid stenting and cerebral protection?

Carotid angioplasty is fast being incorporated into the treatment options for patients with carotid occlusive disease. The results of the SAPPHIRE and ARCHER trials have demonstrated that carotid angioplasty and stenting with the use of cerebral protection devices is not inferior to open surgical endarterectomy in high-risk patients. The limiting step for percutaneous carotid interventions was the potential for cerebral embolization during the intervention. However, the ready availability of several embolic protection devices has placed this technology into the hands of many endovascular specialists. A brief outline of the basic inventory necessary for a carotid stent program is presented.     

Vascular surgery: an update

Caring for patients with vascular illnesses has become increasingly more complex and has changed dramatically over the past 10 years, with a widening array of diagnostic and treatment options. Carotid artery stenting has the potential to become a viable alternative to open surgery in high-risk patients with carotid artery disease (i.e., patients older than 80 years and those with previous neck surgery or irradiation, contralateral carotid artery occlusion, contralateral laryngeal nerve injury, or angina). However, the effectiveness of carotid artery stenting as a therapy is still being evaluated in randomized trials. Endovascular aortic aneurysm repair is an option for patients who desire or require a less invasive modality and who have suitable aortic anatomy. Surgical reconstruction remains the standard treatment for ischemic rest pain and tissue loss (critical limb ischemia). Balloon angioplasty and stenting are treatment options for peripheral vascular disease, although treatment is dependent on the arterial segment or segments involved.     

Platelet glycoprotein IIb/IIIa-receptor inhibitors in patients with acute coronary syndromes or undergoing percutaneous coronary interventions: a review

BACKGROUND: Over 12.2 million Americans are affected by acute coronary syndromes (ACS) resulting from arterial thrombosis after atherosclerotic plaque rupture. The mechanism of thrombosis is based on the platelet activation pathway, facilitated by expression of the platelet glycoprotein (GP) lIb/Illa receptors. The platelet GP IIb/IIIa-receptor inhibitors represent a new class of drugs, of which abciximab, eptifibatide, and tirofiban have been approved for use in the medical management of ACS and as adjunctive therapy in percutaneous coronary interventions (PCIs). OBJECTIVE: This article reviews the results of published multicenter, randomized, placebo-controlled, double-blind trials of the efficacy and safety of platelet GP IIb/IIIa-receptor inhibitors in patients with coronary artery disease. METHODS: To identify articles for this review, a search of MEDLINE for the years 1994 through 2000 was conducted using the key words myocardial ischemia, unstable angina, angioplasty, stent, abciximab, eptifibatide, tirofiban, lamifiban, and platelet aggregation inhibitors. Relevant review articles were consulted as well as reports of clinical studies. CONCLUSIONS: Three GP IIb/IIIa-receptor inhibitors--abciximab, eptifibatide, and tirofiban-are approved by the US Food and Drug Administration as adjunctive therapy in patients undergoing PCI. Eptifibatide and tirofiban 'are also indicated for the medical management of patients with unstable angina and non-ST-segment-elevation myocardial infarction. The use of GP IIb/IIIa-receptor inhibitors as a component of management with fibrinolytic agents is under investigation. Studies comparing the efficacy of tirofiban and abciximab in patients undergoing planned PCI with intracoronary stent placement are in progress. Until data are available from long-term trials and head-to-head comparisons of these agents, it is not possible to generalize about their overall or comparative efficacy.