1. MCV Campus
Ginger Edwards

2. George W. Vetrovec, MD DISCLOSURES Consulting Fees Honoraria
Gilead Sciences, Merck & Co., Inc., Abbott Vascular
Honoraria
Cordis, a Johnson & Johnson company, Eli Lilly and Company, Daiichi Sankyo, Inc., Gilead Sciences
Grants/Contracted Research
Corindus, Inc., Cordis, a Johnson & Johnson company, Merck & Co., Inc.

3. VCU Pauley Heart Center Virginia Commonwealth University
ACS & AMI Management
ACS & NSTEMI: GPIIb IIIa Inhibiters & PCI: For Whom and How Long? How early should we give them?
George W. Vetrovec, MD.
VCU Pauley Heart Center
Virginia Commonwealth University
Richmond, Virginia

4. Coronary Thrombosis in Unstable Angina
The angiogram here illustrates a severe stenosis in the mid Right Coronary Artery with a large filling defect, consistent with thrombsis, just distal to the stenosis. This finding illustrates the thrombotic mechanisms underlying this syndrome.

5. Cardiac enzyme ratio vs 6 mo Mortality
EPIC, EPILOG, and CAPTURE
Cardiac enzyme ratio vs 6 mo Mortality
Centocor- Data on file

6. Updated 2010 PCI/STEMI Guidelines
No Change in PCI Guidelines
for IIbIIIa Use

7. UA/NSTEMI IIb/IIIa Inhibiter Guidelines
CLASS I

8. UA/NSTEMI IIb/IIIa Inhibiter Guidelines
CLASS I

9. UA/NSTEMI IIb/IIIa Inhibiter Guidelines
CLASS IIa

10. UA/NSTEMI IIb/IIIa Inhibiter Guidelines
CLASS IIa

11. UA/NSTEMI IIb/IIIa Inhibiter Guidelines
CLASS IIa

12. UA/NSTEMI IIb/IIIa Inhibiter Guidelines

13. GP IIb/IIIa Prior to PCI in ACS
GP IIb/IIIa Inhibitor
Placebo
n=1239
P=.009
10%
n=1265
P=.032
CAPTURE 5% 0%
10%
n=9461
P=.002
PURSUIT 5%
n=1248
P=.098 0%
10%
n=1570
P=.016
n=287
P=.062
PRISM-PLUS 5% 0%
+24h
+48h
+72h
+24h
+48h
Start GP IIb/IIIa Inhibitor/Placebo
Percutaneous Coronary Intervention
Circulation. 1999;100:

14. Thrombin Inhibiter/Antiplatelet Interactions
Bivalrudin and/or Clopidogrel as Alternatives
ACUITY – 29% increase in Ischemic events if no pre clopidogrel
ISAR-REACT II – Advantage with pre Clopidogrel & Abciximab only Troponin Positive patients.
ISAR REACT III – clopidogrel preloading; Bivalrudin no advantage to Heparin
Summary
Less Bleeding
Similar composite outcomes
Highest risk patients may be somewhat less protected particularly if Clopidogrel not given upstream.

15. ACUITY Results

16. UA/NSTEMI IIb/IIIa Inhibiter Guidelines
Length of Infusion
CAPTURE
ESPRIT
Brief-PCI
Preloading with Clopidogrel may change the need for long infusion post PCI.

17. IIb/IIIa Inhibiters in UA/NSTEMI:2009
No pre clopidogrel loading for urgent ACS
High Risk:
Positive Markers
Large Clot
Diabetes
Complex Anatomy

18. UA/NSTEMI IIb/IIIa Inhibiter Guidelines
Benefit of IIb/IIIa Inhibiters is limited today due to earlier and more potent oral antiplatelet agents – if administered early (clopidogrel) or prior to PCI (prasugrel).
The adjunctive role of other current medicines, particularly statins is unknown in modulating the impact of IIb/IIIa inhibiters
Patients with the highest risk for adverse outcomes with ACS (Markers, ECG Changes) potentially derive the greatest benefit.

19. STEMI IIb/IIIa Inhibiter Guidelines

20. 30 Day Composite Endpoint
Primary PCI for AMI
30 Day Composite Endpoint
Death, MI or Urgent TVR
No abciximab
abciximab
* Includes ischemic
stroke
48%
P = 0.03
53%
P = 0.04
59%
P = 0.01
35%
P = 0.01
57%
P = 0.02
RAPPORT
N = 483
Circ 1998;98:734-41
ISAR-2
N = 401
JACC 2000;35:915-21
ADMIRAL
N = 300
NEJM 2001;41:
CADILLAC*
N = 2082
Circ 2003;108:
ACE*
N = 400
JACC 2003;42:

21. F/U LV Function in Primary PCI Trials
Primary PCI for AMI
F/U LV Function in Primary PCI Trials
Circ 98; 98:
55.9
57.0
60.5
62.2
61.1
61.6 50 55 60 65 70 75 80
ISAR II
ADMIRAL
CADILLAC
n = 72
n = 79
n = 151
n = 149
n = 109
n = 116 %
14 days
6 months
7 months
NEJM 2002; 346:
NEJM 2001; 41:
JACC 2000; 35:
No Abciximab
Abciximab

22. Cardiac Function Parameters at 14 days
Primary PCI for AMI
Neumann et al.
Cardiac Function Parameters at 14 days
 peak flow velocity
(cm/s)
 wall motion index
(SD/Chords)
Global LVEF
(%) 25
0.8 80
p=0.024
p=0.007
p=0.003 62 20
18.1 56
0.6 60
0.44 15
10.4
0.4 40 10
0.15
0.2 20 5
n = 72
n = 80
n = 72
n = 79
n = 72
n = 79
Usual care Abciximab
Circ 1998; 98:

23. STEMI IIb/IIIa Inhibiter Guidelines
Registry Comparative Studies suggest no difference between Abciximab and Eptifibitide or tirofiban. Most outcome data with Abciximab.
Trials of Upstream dosing
Meta analysis of 9 trials - better initial TIMI flow; no late difference in MACE
FINESSE – More bleeding but no better outcomes

24. HORIZONS-AMI
Stone et al NEJM 358; 2218

25. 2010 PCI Update EARLY ACS 9000 pts NSTEMI
IIbIIIa trend to less ischemic complications but more bleeding
NO Clear Answer on Timing and Use

26. STEMI IIb/IIIa Inhibiter Guidelines
IIb/IIIa inhibitors Improve outcome but advantages are lessened by early clopidogrel & in lab prasugrel dosing.
Upstream administration is favorable regards early TIMI flow but late outcome advantages are lacking and bleeding is potentially increased.
Most appropriate as cath lab drug.