Efficacy and Safety of Glycoprotein IIb/IIIa Inhibitors During Elective Coronary Revascularization A meta-analysis of randomized trials performed in the.

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Presentation transcript:

Efficacy and Safety of Glycoprotein IIb/IIIa Inhibitors During Elective Coronary Revascularization A meta-analysis of randomized trials performed in the era of stents and thienopyridines Winchester DE, Wen X, Brearley WD, Park KE, Anderson RD, Bavry AA

Disclosures All authors have no conflicts to disclose This research was supported by an unrestricted grant from the Florida Heart Research Institute

Background and Context Glycoprotein IIb/IIIa inhibitors (GPI) Potent antiplatelet agents Commonly used during percutaneous coronary intervention (PCI) Contemporary PCI typically performed with: Stents Thienopyridines Aim: To assess efficacy and safety of GPI in contemporary elective PCI Hypothesis: Benefits of GPI will be minimal and bleeding risks will be elevated

Methods Meta-analysis of: MEDLINE, Cochrane, clinicaltrials.gov Randomized controlled trials of GPI vs. control DerSimonian-Laird model for risk ratios (RR) STATA v11 (College Station, TX) Independent data extraction by two authors (WDB and KEP) Verification and resolution of disagreements by two authors (DEW and AAB)

Study Selection 6,377 studies identified by search strategy MeSH terms and keywords Limited to humans and clinical trials 648 studies remained Abstracts hand searched and non-elective PCI studies were eliminated 22 studies included in meta-analysis

Outcomes Periprocedural Myocardial Infarction Major Bleeding Minor Bleeding All-cause mortality

Baseline Characteristics Mean age = 63 years Mean percent female = 25% Median stent use = 98% Thienopyridine given prior to PCI in 94% (given after PCI in remainder)

Periprocedural Infarction 5.1% with GPI versus 8.3% with control RR=0.66 (95% CI 0.55 to 0.79), p<0.0001

Major Bleeding 1.2% with GPI versus 0.9% with control RR=1.37 (95% CI 0.83 to 2.25), p=0.22

Minor Bleeding 3.0% with GPI versus 1.7% with control RR=1.70 (95% CI 1.28 to 2.26), p<0.0001

Mortality 0.3% with GPI versus 0.5% with control RR=0.70 (95% CI 0.36 to 1.33), p=0.27

Metaregression Influence of various covariates on myocardial infarction Percentage of patients with diabetes (p = 0.61) Publication year (p = 0.99) Thienopyridine before vs after PCI (p = 0.99) Higher dose of heparin in control arm (p = 0.78)

Limitations Could not stratify patients by other known risk factors Platelet reactivity, statin use, lesion complexity Included ticlopidine studies However, efficacy is considered similar to clopidogrel

Conclusions Using GPI during modern elective PCI with thienopyridines and stenting has the following effects: Postprocedural infarction is significantly reduced, ARR = 3.2%, risk ratio = 0.66 Major bleeding is not significantly increased Minor bleeding is significantly increased, ARR = 1.3%, risk ratio = 1.70 No net effect on mortality Winchester DE, et al JACC 2011