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Medical Sciences	100%

Kinds of IIb/IIIa Inhibitors

georgia-pacific iib/iiia inhibitor

glycoprotein iib/iiia inhibitor

Selected Abstracts

Guidelines to Practice Gap in the Use of Glycoprotein IIb/IIIa Inhibitors: From ISAR-REACT to Overreact?

JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 2 2009
G. VISWANATHAN M.R.C.P.
Adjunctive use of glycoprotein IIb/IIIa inhibitors (GPI) is associated with favorable outcomes following percutaneous coronary intervention (PCI). Guidelines for use of GPI have been published by various national societies including National Institute of Clinical Excellence (NICE), United Kingdom. The latter has not been updated since publication. The impact of contemporary trials such as ISAR-REACT (which showed no benefit of abciximab and 600 mg of clopidogrel compared with 600 mg of clopidogrel alone, in elective patients) on adherence to NICE guidelines is unknown. Methods: We audited use of GPI against NICE guidelines following publication in May 2002. Data were collected from 1,685 patients between September and November in years 2002, 2003, 2004, and 2007. Results: In 2002 and 2003, only 10.2% and 11.8%, respectively, of patients were noncompliant to NICE guidelines. Over time, there was an increase in patients not given GPI despite meeting NICE criteria. After publication of ISAR-REACT, the comparative figures for noncompliance in 2004 and 2007 were 40.0% and 44.5%. A similar pattern was seen in patients with diabetes; in 2002 and 2003 noncompliance was 16.7% and 11.1%, respectively, and in 2004 and 2007 noncompliance was 38.0% and 44.7%, respectively. Qualitatively, similar findings were recorded in patients with NSTE-ACS. The overall noncompliance to NICE guidelines increased from 11.0% to 42.1% (P < 0.0001) after the ISAR-REACT study. Conclusions: We found a decline in compliance to NICE guidelines on GPI usage during PCI. This was likely influenced by contemporary trials demonstrating little or no benefit of GPI in patients undergoing elective PCI who are adequately pretreated with clopidogrel. Our findings suggest the need for a mechanism whereby regular updates to guidelines can be disseminated following new trial evidence. [source]

The Role of Enoxaparin in Interventional Management of Patients with Acute Coronary Syndromes

JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 5 2003
CINDY L. GRINES M.D., F.A.C.C.
Interventional management strategies involving early angiography and percutaneous coronary intervention (PCI) are increasingly widespread in the management of patients with acute coronary syndromes (ACS). Notwithstanding the benefits of early intervention, there is a significant risk of postprocedural thrombotic complications and a need to optimize antithrombotic regimens for use before and during PCI. It is clear that the current standard therapy with unfractionated heparin (UFH) and aspirin can be improved upon, in terms of both efficacy and safety. The low-molecular-weight heparin(s) (LMWHs) offer pharmacologic and practical advantages over UFH. The LMWH enoxaparin has recently emerged as the anticoagulant of choice for the acute management of ACS. Enoxaparin has also demonstrated sustained benefits over UFH in patients proceeding to PCI, and as a procedural anticoagulant. Combination therapy with enoxaparin and a glycoprotein IIb/IIIa inhibitor may further improve the efficacy and safety of antithrombotic treatment during coronary interventions, as a result of the drugs' complementary mechanisms of action. Early clinical evidence supports the use of enoxaparin in combination with glycoprotein IIb/IIIa inhibitors in high-risk patients with ACS. Ongoing, large-scale, randomized controlled studies will help to clarify the role of enoxaparin in interventional cardiology, either as the primary anticoagulant or as part of a combination regimen, and to define optimal regimens for treatment. (J Interven Cardiol 2003;16:357,366) [source]

Impact of an Audit Program and Other Factors on Door-to-balloon Times in Acute ST-elevation Myocardial Infarction Patients Destined for Primary Coronary Intervention

ACADEMIC EMERGENCY MEDICINE, Issue 4 2009
Chao-Lun Lai MD
Abstract Objectives:, This before,after study investigated the association between an audit program and door-to-balloon times in patients with acute ST-elevation myocardial infarction (STEMI) and explored other factors associated with the door-to-balloon time. Methods:, An audit program that collected time data for essential time intervals in acute STEMI was developed with data feedback to both the Department of Emergency Medicine and the Department of Cardiology. The door-to-balloon times for 76 consecutive acute STEMI patients were collected from February 16, 2007, through October 31, 2007, after the implementation of the audit program, as the intervention group. The control group was defined by 104 consecutive acute STEMI patients presenting from April 1, 2006, through February 15, 2007, before the audit was applied. A multivariate linear regression model was used for analysis of factors associated with the door-to-balloon time. Results:, The geometric mean 95% CI of the door-to-balloon time decreased from 164.9 (150.3, 180.9) minutes to 141.9 (127.4, 158.2) minutes (p = 0.039) in the intervention phase. The median door-to-balloon time was 147.5 minutes in the control group and 136.0 minutes in the intervention group (p = 0.09). In the multivariate regression model, the audit program was associated with a shortening of the door-to-balloon time by 35.5 minutes (160.4 minutes vs. 195.9 minutes, p = 0.004); female gender was associated with a mean delay of 58.4 minutes (208.9 minutes vs. 150.5 minutes; p = 0.001); posterolateral wall infarction was associated with a mean delay of 70.5 minutes compared to anterior wall infarction (215.4 minutes vs. 144.9 minutes; p = 0.037) and a mean delay of 69.5 minutes compared to inferior wall infarction (215.4 minutes vs. 145.9 minutes; p = 0.044). The use of a glycoprotein IIb/IIIa inhibitor was associated with a 46.1 minutes mean shortening of door-to-balloon time (155.7 minutes vs. 201.8 minutes; p < 0.001). Conclusions:, The implementation of an audit program was associated with a significant reduction in door-to-balloon times among patients with acute STEMI. In addition, female patients, posterolateral wall infarction territory, and nonuse of glycoprotein IIb/IIIa inhibitor were associated with longer door-to-balloon times. [source]

Transcranial Doppler ultrasonography-directed intravenous glycoprotein IIb/IIIa receptor antagonist therapy to control transient cerebral microemboli before and after carotid endarterectomy,

BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 6 2008
D. van Dellen
Background: Patients with a transient focal neurological deficit, critical carotid stenosis and/or microemboli detected by transcranial Doppler ultrasonography (TCD) have a significant risk of stroke. The effect of tirofiban, a selective glycoprotein IIb/IIIa inhibitor, was assessed in patients with microembolic signals on TCD after transient ischaemic attacks or carotid endarterectomy (CEA). Methods: Thirty-three patients with microemboli on TCD (13 symptomatic preoperative, 19 postoperative, one both) were treated with tirofiban between 2002 and 2007. All patients had carotid stenosis greater than 70 per cent. TCD monitoring was used during and after tirofiban therapy. Results: The median (range) rate of microemboli decreased from 22 (4,260) per h before surgery and 81 (44,216) per h after surgery to 0 (0,9) per h in both groups (P < 0·001, Mann,Whitney U test). This occurred rapidly (preoperative median 30 min; postoperative median 45 min) and was well tolerated in all patients, with no serious adverse effects. Conclusion: Cerebral microemboli were controlled by tirofiban both before and after CEA. Further study is required to compare the relative efficacy of tirofiban and dextran. Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source]

Myocardial protection with a beta blocker and glycoprotein IIb/IIIa inhibitor during PCI: Attractive concept, but limited evidence of benefit,

CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 4 2008
FSCAI, Massoud A. Leesar MD
No abstract is available for this article. [source]

The challenge of ST-segment elevation myocardial infarction

INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 12 2007
M. Cohen
Summary Background/introduction:, Acute coronary syndromes (ACS) represent a spectrum of ischaemic myocardial events that share a similar pathophysiology. ST-segment elevation myocardial infarction (STEMI), the most severe form of ACS short of sudden cardiac death, is a significant public health problem with an estimated 500,000 STEMI events every year in the United States. Treatment/therapy:, The mortality and morbidity associated with STEMI is significant. Early reperfusion therapy is the most important aspect of the treatment of STEMI. There are two main methods of reperfusion therapy: percutaneous coronary intervention (PCI) and fibrinolytic therapy, with PCI being the preferred method. In addition to standard reperfusion therapy, antithrombotics (unfractionated heparin and low molecular weight heparins) and antiplatelet agents (aspirin, clopidogrel and glycoprotein IIb/IIIa inhibitors) are critical adjuncts, effective in the treatment of acute STEMI. Conclusions:, The survival of patients with STEMI depends on rapid diagnosis and optimal early treatment. Guidelines for the management of patients with STEMI recommend PCI within 90 min of presentation and that fibrinolytics are administered within 30 min. However, only a fraction of patients undergo reperfusion within the recommended time. Improvements in protocols for identifying STEMI cases are therefore required to allow reperfusion therapy to be initiated sooner. Secondary prevention is another important aspect of STEMI management, and patients should be encouraged to adopt strategies that reduce the risk of subsequent ischaemic events. [source]

Selection of glycoprotein IIb/IIIa inhibitors for upstream use in patients with diabetes experiencing unstable angina or non-ST segment elevation myocardial infarction.

JOURNAL OF CLINICAL PHARMACY & THERAPEUTICS, Issue 6 2004
What have we learned in the last 10 years?
Summary Coronary disease accounts for the majority of deaths among patients with diabetes and the thrombotic milieu accelerated by diabetes results in unstable angina (UA), non-ST segment elevation myocardial infarction (NSTEMI) or ST-segment elevation myocardial infarction (STEMI) or death. Upstream use of a glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitor with percutaneous coronary intervention (PCI) as part of an early invasive approach is preferred. However substantial numbers of patients present to rural or non-teaching hospitals without immediate access to a catheterization laboratory. Enhanced GP IIb/IIIa receptor mobilization, TXA2 production and platelet activation together present an extensive thrombotic challenge that may not be overcome with current doses of GP IIb/IIIa inhibitors when used without PCI. Heterogeneity of platelet aggregometric analysis may have identified GP IIb/IIIa doses used in clinical trials that may not fully overcome the thrombotic challenge in patients with diabetes. GUSTO-IV ACS failed to demonstrate a difference in mortality when used without PCI. The PURSUIT trial provided evidence that eptifibatide decreases death or non-fatal myocardial infarction (MI) in the main group and in the diabetic subgroup. Reductions in this primary endpoint were driven by the reduction in non-fatal MI. The PRISM and PRISM-PLUS trials demonstrated a reduction in death, MI or refractory ischaemia at 48 h or 7 days in the main cohort but not specifically in patients with diabetes. Data supporting use of GP IIb/IIIa inhibitors are inconsistent, raising the question of whether these agents should be used at all without PCI. Variability in experimental methodology of platelet aggregometry and selection of anticoagulant used during dose finding studies may have generated doses that are insufficient to overcome the thrombotic burden. A new marker of active inflammation, sCD40L is found to be upregulated at subtherapeutic doses of GP IIb/IIIa inhibitors, suggesting that rebound inflammatory processes may partially account for absence of clear evidence of benefit with some GP IIb/IIIa inhibitors in patients with diabetes experiencing UA/NSTEMI. [source]

Guidelines to Practice Gap in the Use of Glycoprotein IIb/IIIa Inhibitors: From ISAR-REACT to Overreact?

Incidence and Predictors of Major Vascular Complications after Percutaneous Coronary Intervention in the Glycoprotein IIb/IIIa Platelet Inhibitor Era

JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 2 2004
RICHARD KONSTANCE M.D.
Since the introduction of platelet glycoprotein (GP) IIb/IIIa inhibitors, reports of vascular complications after percutaneous coronary intervention (PCI) have focused on bleeding and the need for surgical repair, whereas specific major vascular complications have been less consistently identified. Moreover, data from clinical trials may lack applicability to the general population. The purpose of this study was to determine the incidence of major vascular complications after PCI and to identify associated risk factors in patients routinely receiving GP IIb/IIIa inhibitors. During a 12-month period, 1,634 consecutive patients underwent PCI at a single institution. Clinical characteristics and procedural data were collected prospectively; data regarding vascular sheath removal were obtained retrospectively. Univariate and multivariable regression methods were used to identify independent predictors of major vascular complications. Major vascular complications occurred in 2.9% of patients. Multivariable analysis revealed advanced age (odds ratio [OR] 1.05, P = 0.0025) and female sex (OR 2.9, P = 0.0002) as clinical characteristics associated with major vascular complications, whereas hypertension had an inverse relationship (OR 0.46, P = 0.013). Procedural factors included use of the following: stents (OR 5.59, P < 0.0001), vascular sheaths >6F (OR 3.25, P = 0.016), and mechanical clamp (OR 2.71, P = 0.0012). The presence of a hematoma >4 cm2 had a positive predictive value of 12% for major vascular complications. The incidence of major vascular complications in this large, single-center study from the GP IIb/IIIa inhibitor era is consistent with data from the pre-GP IIb/IIIa inhibitor era and recent randomized trials. (J Interven Cardiol 2004;17:65,70) [source]

The Role of Enoxaparin in Interventional Management of Patients with Acute Coronary Syndromes

Platelet hyperprocoagulant activity in Type 2 diabetes mellitus: attenuation by glycoprotein IIb/IIIa inhibition

JOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 12 2008
M. RAZMARA
Summary.,Background:,Platelets are hyperactive in Type 2 diabetes mellitus (T2DM), and antiplatelet treatment with glycoprotein (GP) IIb/IIIa inhibitors provides better thrombotic protection in DM than in non-diabetic subjects. Objective:,We hypothesized that diabetic platelets are hyperprocoagulant, and that this hyperactivity can be inhibited by GPIIb/IIIa blockade. Methods:,Patients with T2DM and gender/age/body mass index-matched non-diabetic controls were recruited (n = 12 for both) to study the effect of GPIIb/IIIa blockade on platelet procoagulant activity. Platelet phosphotidylserine (PS), factor (F) Va expression, and platelet-derived microparticle (PDMP) generation were measured by whole blood flow cytometry. Platelet-dependent thrombin generation and plasma clotting time were monitored in recalcified platelet-rich plasma. Results:,Compared to controls, basal platelet activation was similar, while thrombin receptor activating peptide stimulated activation was enhanced in patients with T2DM. Diabetic platelets also displayed more profound elevations of platelet PS exposure, FVa binding, and PDMP generation upon stimulation. These alterations resulted in a hyperprocoagulant state, as evidenced by a marked increase in the platelet procoagulant index, enhanced thrombin generation, and a shortened plasma clotting time. GPIIb/IIIa blockade by c7E3 or SR121566 decreased platelet PS exposure and FVa binding, and diminished platelet procoagulant activity in patients with T2DM. Conclusions:,Platelets have increased procoagulant activity in patients with T2DM. The hyperprocoagulant activity is counteracted by GPIIb/IIIa blockade. [source]

Point-of-care testing shows clinically relevant variation in the degree of inhibition of platelets by standard-dose abciximab therapy during percutaneous coronary intervention

CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 2 2004
Michael J. Ray PhD
Abstract Administration of GP IIb/IIIa inhibitors during percutaneous coronary intervention (PCI) has proven clinical benefit, but is administered at a dose allowing for the patients' weight but not other variables. This study of 75 patients evaluated platelet inhibition achieved by standard-dose abciximab therapy during PCI as measured by two point-of-care (POC) instruments, Plateletworks (PW) and whole blood aggregation (WB). Results were related to the decrease of platelet activation produced as well as patients' return of angina within 30 days. Flow cytometric measurement showed abciximab suppressed platelet-monocyte aggregates (P < 0.001) and activated glycoprotein IIb/IIIa (P < 0.001) but not P-selectin. Greater POC-measured inhibition corresponded to less postabciximab expression of platelet-monocyte aggregates (P < 0.01). Patients above the lowest quartile of POC inhibition with PW demonstrated a relative risk of experiencing return of angina within 30 days of 0.48 (0.23,0.99). In conclusion, POC measurements reflect platelet activation suppression, higher PW measurements being associated with a decreased risk of return of angina. Catheter Cardiovasc Interv 2004;62:150,154. © 2004 Wiley-Liss, Inc. [source]

Stenting and glycoprotein IIb/IIIa inhibition in patients with acute myocardial infarction undergoing percutaneous coronary intervention: Findings from the global registry of acute coronary events (GRACE)

CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 3 2003
Gilles Montalescot MD
Abstract Stenting and GP IIb/IIIa inhibition are promising adjunctive therapies in PCI. The Global Registry of Acute Coronary Events (GRACE) is a registry of unselected patients with acute coronary syndromes, allowing for the study of treatments in a real-world environment. Data from GRACE patients with AMI who underwent PCI were analyzed. After adjusting for demographics, baseline characteristics, and previous medications, treatment with GP IIb/IIIa inhibitors and a stent and treatment with a stent alone were significant predictors of survival at 6 months. Stents were used in 90.9% of patients. GP IIb/IIIa inhibitors were used in 59.7%; in most cases they were started after the beginning of the procedure. The in-hospital death rate (7.6%) was highest in patients undergoing urgent PCI. Mortality at 6 months following PCI was 14.4% among patients who received neither GP IIb/IIIa inhibitors nor a stent, compared to patients who received both GP IIb/IIIa inhibitors and a stent (7.3%), GP IIb/IIIa inhibitors alone (12.8%), or a stent alone (6.7%) Catheter Cardiovasc Interv 2003;60:360,367. © 2003 Wiley-Liss, Inc. [source]

Randomized comparison of vasoseal and angioseal closure devices in patients undergoing coronary angiography and angioplasty

CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 4 2002
Nicolas W. Shammas MD
Abstract AngioSeal (AS) and VasoSeal (VS) are collagen-based arterial closure devices utilized to achieve earlier hemostasis and ambulation in diagnostic and interventional percutaneous procedures. To our knowledge, there has been no randomized studies comparing these two devices as approved for use in the United States. One hundred fifty-seven patients were randomized to receive either the 8 Fr AS (n = 79) or VS (n = 78) closure device. Data on 95 patients who had coronary angiography (49 AS, 46 VS) and 55 patients who underwent angioplasty (28 AS, 27 VS) were completed. Heparin was not administered during the coronary angiogram procedure. The activated clotting time was kept at approximately 300 sec during angioplasty. Patients on coumadin or GP IIb/IIIa platelet inhibitors were not included in this study. The time unit interval to achieve hemostasis in this study was based on the time the AS tension spring was left over the common femoral artery following collagen deployment as per the manufacturer's instructions (20 min). Time to hemostasis, time to ambulation, and major and minor complications were prospectively recorded. Two-tailed t -test and chi-square analysis were performed on continuous and dichotomous variables, respectively. For the angiogram-only subgroup, time (min) to hemostasis (20.51 ± 4.36 vs. 18.59 ± 11.77; P = 0.30) and ambulation (145.71 ± 124 vs. 109.89 ± 60.37; P = 0.075) were not statistically different for the AS and VS, respectively. Similarly, for the angioplasty subgroup, time (min) to hemostasis (24.23 ± 12.70 vs. 19.57 ± 2.27; P = 0.077) and ambulation (607.32 ± 344.22 vs. 486.48 ± 200.37; P = 0.12) were not statistically different for both AS and VS, respectively. Furthermore, there were no statistical differences in deployment failure, major, minor, or total complication rates between the two devices. In the absence of GP IIb/IIIa inhibitors, VS and the 8 Fr AS devices have statistically similar time to hemostasis and ambulation as well as device failures and complication rates following coronary angiography and angioplasty. Cathet Cardiovasc Intervent 2002;55:421,425. © 2002 Wiley-Liss, Inc. [source]

Antiplatelet Strategies: Evaluating Their Current Role in the Setting of Acute Coronary Syndromes

CLINICAL CARDIOLOGY, Issue S1 2008
Eugene Braunwald
Abstract Numerous clinical trials have established the value of antiplatelet therapies for acute coronary syndromes (ACS). Aspirin (ASA), thienopyridines (i.e., clopidogrel and ticlopidine) and GP IIb/IIIa antagonists comprise the major classes of antiplatelet therapies demonstrated to be of benefit in the treatment of ACS and for the prevention of thrombotic complications of percutaneous coronary intervention (PCI). Clopidogrel is beneficial when administered before and after PCI, and is more effective when combined with either ASA or GP IIb/IIIa inhibitors in preventing post-PCI complications, coronary subacute stent thrombosis, and thrombotic events in general. It is currently unclear whether a higher loading dose of clopidogrel (600 mg) is better than the standard loading dose (300 mg), how long therapy should continue, and which maintenance dose is optimal. The role of the GP IIb/IIIa antagonists in ACS is less clear due to conflicting data from several studies with different patient populations. Currently, it appears that the use of GP IIb/IIIa antagonists might be most beneficial in high-risk ACS patients scheduled to undergo PCI, who demonstrate non-ST-segment elevation myocardial infarction and elevated troponin levels. Copyright © 2008 Wiley Periodicals, Inc. [source]

Evolution of Anticoagulant and Antiplatelet Therapy: Benefits and Risks of Contemporary Pharmacologic Agents and Their Implications for Myonecrosis and Bleeding in Percutaneous Coronary Intervention

CLINICAL CARDIOLOGY, Issue S2 2007
Hector M. Medina M.D., M.P.H.
Abstract Periprocedural myonecrosis, as evidenced by elevated creatine kinase,myocardial bound (CK-MB) levels, occurs in up to 25% of patients undergoing percutaneous coronary intervention (PCI) and has been linked with an increased risk of adverse short- and long-term clinical outcomes. Such myonecrosis arises from three main pathophysiological mechanisms: procedure-related complications, lesion-specific characteristics (e.g., large thrombus burden, plaque volume), and patient-specific characteristics (e.g., genetic predisposition, arterial inflammation). Periprocedural myonecrosis has not been definitively identified as the cause of postprocedural ischemic events, although agents that reduce or prevent thrombosis,including aspirin, thienopyridines, heparin, low-molecular-weight heparins, glycoprotein IIb/IIIa inhibitors, and direct thrombin inhibitors,have been shown to reduce the incidence of ischemic outcomes in this population, as have agents that reduce inflammation (aspirin, statins). At the same time, antithrombotic agents are known to increase the risk of bleeding and the use of transfusions, which have likewise been associated with worse outcomes in these patients. Thus, optimal management of patients undergoing PCI represents a balance between minimizing the risk of ischemic outcomes and simultaneously minimizing the risk of major bleeding. It may be that patients who have only minor, untreated postprocedural elevations in CK-MB level (with no clinical or angiographic signs of ischemia) might have a better prognosis than patients who have normal CK-MB levels but who suffer major bleeding complications. Copyright © 2007 Wiley Periodicals, Inc. [source]