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The use of glycoprotein IIb/IIIa inhibitors in elective PCI - A systematic review and meta-analysis of randomised
Daniel G Brieger1, Karan Rao1, Vinayak Nagaraja2
1Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia; University of Sydney, Camperdown, Sydney, NSW, Australia.
Insights
Glycoprotein IIb/IIIa inhibitors (GPIs) reduce major adverse cardiac events and stent thrombosis after elective percutaneous coronary intervention. However, their benefits have decreased over time, with increased minor bleeding risk.
Area of Science:
- Cardiology
- Interventional Cardiology
- Pharmacology
Background:
- Glycoprotein IIb/IIIa inhibitors (GPIs) are used in acute coronary syndromes but their role in stable coronary artery disease (CAD) with modern stents is unclear.
- Oral antiplatelet therapy has advanced, necessitating a re-evaluation of GPIs in elective percutaneous coronary intervention (PCI).
Purpose of the Study:
- To systematically evaluate the efficacy and safety of GPIs as an adjunct to elective PCI.
- To assess the impact of GPIs on major adverse cardiac events (MACE), stent thrombosis (ST), target vessel revascularisation (TVR), and bleeding.
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials comparing GPIs to placebo in elective PCI.
- Searched databases including PubMed, EMBASE, Central, and clinicaltrials.gov up to October 2022.
- Analyzed outcomes at 30 days and 6-12 months, including MACE, ST, TVR, and bleeding using a random-effects model.
Main Results:
- 16 studies with 6428 patients were included.
- GPIs significantly reduced 30-day MACE (RR 0.58) and intermediate-term MACE (RR 0.67), and ST (RR 0.29).
- Minor bleeding risk increased (RR 1.72), but no significant difference in TVR or major bleeding was observed. Meta-regression indicated a waning benefit over time.
Conclusions:
- GPI use in elective PCI reduces MACE and ST but increases minor bleeding.
- The diminishing benefit over time suggests a need for selective use.
- GPIs should be considered for patients at low bleeding risk undergoing elective PCI.
Background:
Glycoprotein IIb/IIIa inhibitors (GPIs) improve 30-day outcomes when used as an adjunct to percutaneous coronary intervention (PCI) in acute coronary syndromes, but their role in stable coronary artery disease (CAD) remains uncertain in the context of modern stents and oral antiplatelet therapy.
Methodology:
A systematic search of PubMed, EMBASE, Central and clinicaltrials.gov databases was conducted from inception to October 2022. Randomised trials comparing GPI to placebo in elective PCI were included. Outcomes included target vessel revascularisation (TVR), stent thrombosis (ST) and a composite of TVR, myocardial infarction and death (MACE) at 30-days and 6-12 months. Bleeding was assessed using Thrombolysis In Myocardial Infarction bleeding score or equivalent. A random-effects model was used for all analyses.
Results:
Of 2375 abstracts screened, 16 studies (6428 patients) were included. GPIs significantly reduced 30-day MACE (risk ratio [RR] 0.58, 95 % CI, 0.39-0.86, p < 0.01; number needed to treat = 33), intermediate-term MACE at 6-12 months (RR 0.67; 95 % CI, 0.49-0.92; p = 0.01) and ST (RR 0.29, 95 % CI, 0.10-0.83, p = 0.02). There was no significant difference in TVR or major bleeding, although minor bleeding was increased (RR 1.72, 95 % CI, 1.14-2.61, p = 0.01, number needed to harm = 77). Meta-regression suggested that the benefit of GPIs has diminished over time.
Conclusion:
GPI use during elective PCI reduces MACE and ST whilst increasing minor bleeding. The observed benefit appears to have waned over time, highlighting the importance of selective use in patients at low bleeding risk.
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