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.

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:
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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
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Periprocedural Myocardial Infarction
Major Bleeding
Minor Bleeding
All-cause mortality
Baseline Characteristics
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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
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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