• Int. J. Cardiol. · Mar 2012

    Review Meta Analysis

    Routine upstream versus selective downstream administration of glycoprotein IIb/IIIa inhibitors in patients with non-ST-elevation acute coronary syndromes: a meta-analysis of randomized trials.

    • Alessandro Sciahbasi, Giuseppe Biondi-Zoccai, Enrico Romagnoli, Marco Valgimigli, Saman Rasoul, Arnoud van't Hof, Ernesto Lioy, and Gregg W Stone.
    • Policlinico Casilino-ASL RMB, Rome, Italy. alessandro.sciahbasi@fastwebnet.it
    • Int. J. Cardiol. 2012 Mar 8;155(2):243-8.

    BackgroundGlycoprotein (GP) IIb/IIIa inhibitors reduce ischemic complications in patients with non-ST-elevation acute coronary syndromes (NSTEACS) who undergo invasive procedures. However the optimal timing of therapy (upstream - at hospital admission in all patients prior to coronary catheterization, or downstream - after coronary angiography selectively in patients prior to percutaneous coronary intervention) is still debated. The aim of this meta-analysis was to compare the outcome of NSTEACS patients randomized to routine upstream versus deferred selective downstream GP IIb/IIIa inhibitors.MethodsWe scanned the literature from January 1990 to May 2009 to identify all randomized trials comparing upstream administration of GP IIb/IIIa inhibitors versus its downstream use in invasively managed NSTEACS.ResultsIn 5 randomized trials a total of 9753 patients were randomized to upstream GP IIb/IIIa inhibitors therapy versus 9716 patients randomized to deferred selective downstream therapy. Upstream therapy was associated with reduced in-hospital or 30-day major adverse ischemic cardiac events (odds ratio=0.90 [95% confidence interval 0.82-0.98], p=0.02). However the risk of major bleeding was significantly higher with upstream therapy (odds ratio=1.35 [1.11-1.63], p=0.002). Combining ischemic and hemorrhagic events in a net clinical end-point showed no significant differences between the two approaches (odds ratio=1.01 [0.92-1.10], p=0.88).ConclusionsIn conclusion early administration of GP IIb/IIIa inhibitors in NSTEACS is associated with significant reduction in ischemic events compared to a selective deferred therapy after coronary angiography. However upstream therapy is also associated with increased bleeding complications. This approach should therefore be reserved for patients at high ischemic and/or low hemorrhagic risk.Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

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