For over one decade Glycoproteins IIb/IIIa inhibitors (GPI) have been administered

For over one decade Glycoproteins IIb/IIIa inhibitors (GPI) have been administered to prevent coronary artery thrombosis. of bleeding vascular complications and thrombocytopenia. The clinical and ecomomic burden of major bleeding and thrombocytopenia is usually substantial. The ACUITY trial has initiate a new debate regarding the efficacy and safety of GPI. Selective Alosetron “patient-tailored” use of GPI limited to moderate-high risk PCI patients with low bleeding propensity is usually suggested. Research of new algorithms emphasizing abbreviated GPI administration careful access Alosetron site and bleeding surveillance in conjunction with lower doses of unfractionated heparin or new and safer anti-thrombins may further enhance patient safety. INTRODUCTION GPI are used as adjunctive therapy for 60-70% of PCIs performed in the USA. This review attempts to summarize the current data around the efficacy and safety of these brokers in PCI. In view of the data potential modification of treatment Alosetron algorithms is usually discussed. EFFICACY OF GPI (TABLE ?(TABLE11) Table 1 GPI RCTs- Effect on FGF22 1-6 Months Mortality Mortality Data None of the individual GPI randomized clinical trials (RCTs) was ever able to demonstrate statistically-significant mortality reduction in any clinical setting. However some RCTs detected a favorable pattern towards 20-30% relative risk reduction mortality in certain patient subsets. In order to show statistically significant mortality benefit certain publications employed sub-analysis while others have engaged in meta-analysis. The latter bring to the scientific arena complex validity concerns when performed quantitatively (due to increased risk of type I error). The need to change Alosetron thresholds for statistical significance to account for multiple investigations or for potential heterogeneity is usually subject Alosetron for methodological debates. Moreover “publication bias” can further erode the meta-analysis validity: studies with unfavorable outcome are discontinued not reported or remain unpublished and if published are omitted from meta-analysis. As an example: 4 phase 3 RCTs of oral-GPI in ACSWSTE [1 2 which together enrolled 33 326 patients demonstrated 31% excess mortality in the GPI arm (OR = 1.31; 95% CI: 1.12 to 1 1.53; P= 0.0001). Moreover the incidence of myocardial infarction increased (OR = 1.16; 95% CI: 1.03 to 1 1.29). These studies as well as other studies of oral GPI were not incorporated into the following meta-analysis. The applicability and relevance GPI-RCTs around the contemporary cardiovascular arena is usually further diminished by certain issues (a) Certain patients were deliberately excluded from most these studies: especially patients who were considered high cardiovascular or bleeding risk (elderly patients with heart renal or hepatic failure history of bleeding renal insufficiency or cerebrovascular disease). (b) Most of the trials have carefully tracked ischemic events. The most frequently reported endpoint was post-PCI enzyme rise (CPK>2-3 occasions the upper limit of normal) that were named “myocardial infarctions”. The medical and economic impact of these surrogate laboratory end-points on patient outcome (like cardiovascular mortality medical costs length of hospital stay and patient well-being) was not usually ascertained. (c) Attempt to prospectively account for the clinical consequences of various drug-related adverse events (including: minor and major bleeding vascular complications transfusions thrombocytopenia and allergic reactions) on patients’ outcome was not diligently delineated. (d) From the time the studies were executed the practice of interventional cardiology has undergone considerable change: with the inception of routine versatile stenting pre-PCI high dose (600 mg) clopidogrel new safe and effective anti-thrombins and optimal stenting enhanced by and pre and post-PCI lesion assessment by intravascular ultrasound and pressure wire. As mentioned before individual GPI RCTs failed to demonstrate significant mortality reduction. The pattern of reduced mortality and ischemic events was not homogenous across patient subsets and studies. In the absence of significant treatment effect on mortality in individual RCTs meta-analysis were introduced: At 2003 a meta-analysis [3] of 12 trials (and over 20 0 PCI patients) exhibited a statistically significant mortality reduction at 30 days (OR 0.73 95 CI 0.55 to 0.96 p = 0.024 and number needed to treat to save 1 life was.