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For thrombus inhibition before percutaneous coronary intervention (PCI), a high-dose bolus of tirofiban (Aggrastat) in combination with anticoagulation beat conventional heparin and bivalirudin strategies, according to a meta-analysis presented at the Cardiovascular Research Technologies meeting.

The meta-analysis -- which was selected as an investigation with innovative implications -- found that even with provisional glycoprotein IIb/IIIa inhibitor (GPI) use, heparin and bivalirudin fell to tirofiban, exhibiting higher associations with 30-day major adverse cardiovascular events (OR 1.63 for heparin, 95% CI 1.22-2.15; OR 1.55 for bivalirudin, 95% CI 1.1-2.13).

Rates of all-cause mortality similarly favored tirofiban over heparin (OR 1.76, 95% CI 1.11-2.69) and even another GPI, eptifibatide (OR 2.26, 95% CI 1.0-5.3), reported , of MedStar Washington Hospital Center.

"High-dose tirofiban with anti-coagulation performs well for reduction of all-cause mortality and ischemic events compared with other regimens for percutaneous coronary intervention," he concluded

The latest P2Y12 inhibitors "may not work as fast as you think," Lipinski reasoned, marking an opportunity for GPIs such as tirofiban.

"I feel vindicated," said session panelist , of Atlanta's Emory Saint Joseph's Hospital, who took well to Lipinski's findings.

King was an investigator of , which narrowly failed to find a significant reduction in adverse cardiac events by tirofiban in 1997. The current study brings to light certain points that "we all advocated back then," he said, including the reconsideration of optimal tirofiban dosage and duration of treatment.

The meta-analysis included 38,645 patients from 41 clinical trials.

Lipinski's findings come with several caveats. Tirofiban came in a close second to eptifibatide for myocardial infarction (OR 0.68, 95% CI 0.33-1.34). Additionally, bivalirudin beat tirofiban when it came to major bleeding (OR 0.5, 95% CI 0.27-0.89) and minor bleeding (OR 0.56, 95% CI 0.34-0.82).

Notwithstanding the nature of a meta-analysis, Lipinski acknowledged several other limitations.

He noted that the majority (72%) of patients received clopidogrel as their anticoagulant. "This may be a problem as there is inadequate P2Y12 inhibition in some of the earlier studies with a heparin comparison," he continued.

"Furthermore, the vast majority of the data was obtained through the femoral approach, and this may be associated with a greater risk of bleeding," Lipinski added.

Nonetheless, "it's important to note that if you have thrombus propagation, I think switching to a GPI is going to provide the best oppression of further thrombus propagation," said Lipinski, who conceded that "further studies are necessary to determine whether a single high-dose bolus tirofiban strategy can reduce bleeding risk after PCI."

In the meantime, others wondered where tirofiban would stand in the current sea of antiplatelet strategies. "Is it a new day with the approval of cangrelor?," asked session panelist Maurice Buchbinder, MD, of Alvarado Hospital in San Diego, Calif.

"I think a comparison of cangrelor [Kengreal] and single high-dose bolus tirofiban would be a great idea," Lipinski answered, suggesting that upcoming data to be presented at the European Society of Cardiology Congress 2016 may address that issue.

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