ACC/AHA UA/NSTEMI Guidelines:

Role of GP IIb/IIIa Inhibitors

VBWG

A platelet GP IIb/IIIa antagonist should be administered in addition to ASA and heparin to patients in whom cardiac catheterization and PCI are planned. GP IIb/IIIa antagonists may also be administered just prior to PCI.

II IIaIIa IIbIIb IIIIII

Eptifibatide or tirofiban should be administered in addition to ASA and heparin in patients with continuing ischemia, elevated troponin, or other high-risk features in whom an invasive management strategy is not planned.

A platelet GP IIb/IIIa antagonist should be administered to patients already receiving heparin, ASA, and clopidogrel in whom cardiac catheterization and PCI are planned. GP IIb/IIIa antagonists may also be administered just prior to PCI.

Braunwald E et al. J Am Coll Cardiol. 2002;40:1366-74.

ACC/AHA guidelines for UA/NSTEMI: GP IIb/IIIa inhibitors

VBWG

High-risk patients• Signs of ischemia at rest >20 minutes AND ST-segment

depression and/or elevated cardiac biomarkers

Diagnostic catheterization and revascularization within 24–48 hours (Class Ia)

Adapted from Braunwald E et al. J Am Coll Cardiol. 2002;40;1366-74.

ACC/AHA UA/NSTEMI Guidelines: Management of high-risk patients

Immediate treatment (Class Ia)• ASA or clopidogrel if ASA contraindicated • LMWH or UFH• GP IIb/IIIa inhibitor

VBWG

Boersma E et al. Lancet. 2002;359:189-98.Hoekstra JW et al. Acad Emerg Med. 2005;12:431-8.

RCT = randomized control trialTn+ = troponin positive

0.88 (0.79–0.97)NRMI NSTEMI(n = 60,770)

Adjusted OR (95% Cl)Favorsearly GP IIb/IIIa

inhibitor

Favors no early GP IIb/IIIainhibitor

0.93 (0.83–1.05)CRUSADE ACS(N = 49,378)

0.88 (0.77–1.01)CRUSADE Tn+(n = 32,290)

0.5 1.0 2.0

Odds ratio

6 RCTs ACS(N = 31,402)

0.91 (0.81–1.02)

Mortality risk is lower with early (<24-hour) GP IIb/IIIa inhibition

VBWG

Braunwald E et al. J Am Coll Cardiol. 2002;40:1355-74.

Recommended therapies for UA/NSTEMI

• Aspirin

-Blocker

• Heparin (UFH or LMWH)

• GP IIb/IIIa inhibitor (all receiving PCI/cath)

• Clopidogrel (all receiving PCI)

• Catheterization/revascularization ≤48 hours

• Aspirin

• Clopidogrel

-Blocker

• ACE inhibitor

• Statin/lipid lowering

• Smoking cessation

• Cardiac rehabilitation

Acute therapies (<24h) Discharge therapies

VBWG

12

40

52

63

82

0

20

40

60

80

100

Patients (%)*

CRUSADE registry data: October 1, 2004–September 30, 2005 (n = 35,897)

CRUSADE. www.crusadeqi.com*Without contraindication to catheterization

Cath Cath<48 hr

PCI PCI<48 hr

CABG

Majority of ACS patients undergo catheterization