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      Efficacy and safety of quadruple therapy including tirofiban in the treatment of Chinese NSTE-ACS patients failing to receive timely percutaneous coronary intervention

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          Abstract

          Background

          Although it has been shown to be superior to simple antithrombotic drug therapy, most patients are unable to receive timely percutaneous coronary intervention (PCI) and are treated with conventional triple antithrombotic therapy (aspirin, clopidogrel, low-molecular-weight heparin). Here, we evaluate the efficacy and safety of adding low-dose tirofiban to this regimen.

          Methods

          A total of 1,783 patient records (unable to receive PCI) indicating non-ST-segment elevation acute coronary syndrome (NSTE-ACS) were included. A total of 882 received conventional triple antithrombotic therapy; 901 received quadruple antithrombotic therapy. Efficacy was evaluated in terms of major adverse cardiovascular event (MACE) parameters. Safety was evaluated based on the occurrence of bleeding events. Data were collected over a 6-month period post treatment.

          Results

          The rate of occurrence of MACE was significantly lower in the quadruple antithrombotic group (10.5% versus 14.1% at 6 months, P=0.02). The log-rank test showed improved survival in the quadruple antithrombotic group. Total bleeding events were higher in the quadruple antithrombotic group (9.7%) than in the triple antithrombotic group (7.1%) ( P=0.04); however, this may be attributed to increased clinically insignificant minor bleeding events.

          Conclusion

          Quadruple antithrombotic therapy demonstrated a superior alternative for the treatment of high-risk NSTE-ACS patients failing to receive PCI.

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          Most cited references 18

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          Baseline risk of major bleeding in non-ST-segment-elevation myocardial infarction: the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) Bleeding Score.

          Treatments for non-ST-segment-elevation myocardial infarction (NSTEMI) reduce ischemic events but increase bleeding. Baseline prediction of bleeding risk can complement ischemic risk prediction for optimization of NSTEMI care; however, existing models are not well suited for this purpose. We developed (n=71 277) and validated (n=17 857) a model that identifies 8 independent baseline predictors of in-hospital major bleeding among community-treated NSTEMI patients enrolled in the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) Quality Improvement Initiative. Model performance was tested by c statistics in the derivation and validation cohorts and according to postadmission treatment (ie, invasive and antithrombotic therapy). The CRUSADE bleeding score (range 1 to 100 points) was created by assignment of weighted integers that corresponded to the coefficient of each variable. The rate of major bleeding increased by bleeding risk score quintiles: 3.1% for those at very low risk (score 50; P(trend) or = 2 antithrombotics=0.72; <2 antithrombotics=0.73; invasive approach=0.73; conservative approach=0.68. The CRUSADE bleeding score quantifies risk for in-hospital major bleeding across all postadmission treatments, which enhances baseline risk assessment for NSTEMI care.
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            2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons.

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              Intervention in acute coronary syndromes: do patients undergo intervention on the basis of their risk characteristics? The Global Registry of Acute Coronary Events (GRACE).

              To determine whether revascularisation is more likely to be performed in higher-risk patients and whether the findings are influenced by hospitals adopting more or less aggressive revascularisation strategies. GRACE (Global Registry of Acute Coronary Events) is a multinational, observational cohort study. This study involved 24,189 patients enrolled at 73 hospitals with on-site angiographic facilities. Overall, 32.5% of patients with a non-ST elevation acute coronary syndrome (ACS) underwent percutaneous coronary intervention (PCI; 53.7% in ST segment elevation myocardial infarction (STEMI)) and 7.2% underwent coronary artery bypass grafting (CABG; 4.0% in STEMI). The cumulative rate of in-hospital death rose correspondingly with the GRACE risk score (variables: age, Killip class, systolic blood pressure, ST segment deviation, cardiac arrest at admission, serum creatinine, raised cardiac markers, heart rate), from 1.2% in low-risk to 3.3% in medium-risk and 13.0% in high-risk patients (c statistic = 0.83). PCI procedures were more likely to be performed in low- (40% non-STEMI, 60% STEMI) than medium- (35%, 54%) or high-risk patients (25%, 41%). No such gradient was apparent for patients undergoing CABG. These findings were seen in STEMI and non-ST elevation ACS, in all geographical regions and irrespective of whether hospitals adopted low (4.2-33.7%, n = 7210 observations), medium (35.7-51.4%, n = 7913 observations) or high rates (52.6-77.0%, n = 8942 observations) of intervention. A risk-averse strategy to angiography appears to be widely adopted. Proceeding to PCI relates to referral practice and angiographic findings rather than the patient's risk status. Systematic and accurate risk stratification may allow higher-risk patients to be selected for revascularisation procedures, in contrast to current international practice.
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                Author and article information

                Journal
                Drug Des Devel Ther
                Drug Des Devel Ther
                Drug Design, Development and Therapy
                Drug Design, Development and Therapy
                Dove Medical Press
                1177-8881
                2017
                21 November 2017
                : 11
                : 3299-3307
                Affiliations
                [1 ]Coronary Care Unit, The Traditional Chinese Medicine Hospital, Xinjiang Medical University
                [2 ]Department of Cardiology, General Hospital of Xinjiang Military Command
                [3 ]Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, People’s Republic of China
                Author notes
                Correspondence: Shubin Jiang, Coronary Care Unit, The Traditional Chinese Medicine Hospital, Xinjiang Medical University, No 116, Yellow River Road, Urumqi, Xinjiang-830000, People’s Republic of China, Email shubin.jiang@ 123456yahoo.com
                Article
                dddt-11-3299
                10.2147/DDDT.S138714
                5701602
                © 2017 Li et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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