What is the role of glycoprotein inhibitor therapy following percutaneous coronary intervention (PCI)?

Updated: Nov 27, 2019
  • Author: George A Stouffer, III, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

PCI results in disruption of the coronary endothelium, which leads to platelet activation. Activated platelets bind to the vessel wall (adhesion) and to each other (aggregation) and release numerous vasoactive compounds.

Aspirin blocks the cyclooxygenase pathway and reduces thrombotic complications after balloon angioplasty. However, despite heparin and aspirin therapy, thrombotic complications are not eliminated. Studies identified the importance of the GPIIb/IIIa receptor, which binds fibrinogen and mediates platelet cross-linking and aggregation. The introduction of GP IIb/IIIa inhibitors had a major influence on PCI treatment strategies in the 1990s, but these drugs are now used much less frequently than they once were.

Early studies of GPIIb/IIIa inhibitors showed the following:

  • Abciximab, tirofiban, and eptifibatide are capable of reducing ischemic complications in patients undergoing balloon angioplasty and coronary stenting
  • In primary PCI, GPIIb/IIIa inhibitors can improve flow and perfusion and reduce adverse events
  • Abciximab may improve outcomes in patients when given before arrival in the catheterization laboratory for primary PCI [112]
  • A meta-analysis of GPIIb/IIIa inhibitor trials showed a significant reduction in early mortality when these agents are used during coronary intervention; the combined endpoint of death or MI was also reduced significantly at 30 days
  • The EVA-AMI (Eptifibatide vs Abciximab in Primary PCI for Acute ST Elevation Myocardial Infarction) trial, which compared the efficacy of two GPIIb/IIIa inhibitors as adjuncts to PCI in 427 patients with STEMI, showed that double-bolus eptifibatide followed by a 24-hour infusion was as effective as single-bolus abciximab followed by a 12-hour infusion for ST-segment resolution [113]
  • These agents are effective at reducing ischemic complications of PCI; however, they have not been shown to improve outcome in saphenous vein graft PCI
  • A meta-analysis of 22 studies including 10,123 patients evaluated the use of GPIIb/IIIa inhibitors during elective PCI in patients pretreated with clopidogrel determined that GPIIb/IIIa inhibitors had no effect on mortality or major bleeding but were associated with a decrease in the incidence of nonfatal MI and an increase in the rate of minor bleeding [114]

The evidence supporting the use of GPIIb/IIIa inhibitors derives largely from the time before the widespread use of oral P2Y12 inhibitors. Several studies failed to show a benefit with upstream administration of GPIIb/IIIa inhibitors. In view of these findings, coupled with the increased risk of bleeding, routine use of these agents is no longer recommended. GPIIb/IIIa inhibitors may be used as an adjunctive therapy at the time of PCI, on an individual basis, for large thrombus burden or inadequate P2Y12 receptor antagonist loading.


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