JIM Today 2018 - Saturday - page 5

Issue 3 
Saturday
 24 February 2018 
JIM today
5
In defense of GPIs in high risk ACS
A
lberto Menozzi (University Hospital of
Parma, Italy) joined others to discuss the
crossroads on antithrombotic therapy for
patients treated with PCI yesterday at JIM 2018.
Dr Menozzi argued that, in contrast to current
guidelines, there remains a justification for the
use of intravenous glycoprotein IIb/IIIa inhibitors
(GPIs) in high thrombotic risk patients with acute
coronary syndrome (ACS) despite the availability of
potent oral antiplatelet agents and direct throm-
bin inhibitors.
GPIs were a key drug during the development
of primary PCI in general during the 1990s. They
confer a powerful antithrombotic effect, which
is partially hampered by an increase in bleeding
risk
1
. Within the last decade, increasing concern
for patients’ bleeding risk, coupled with increasing
availability of new oral antiplatelet drugs targeting
thrombosis pathways (e.g. ticagrelor and prasug-
rel), have led to a drop in the use of GPIs.
“We have progressively seen a reduction in the
use of GPIs, and a rapid downgrade of the indica-
tion by guidelines,” said Dr Menozzi in conversa-
tion with
JIM Today
. “In the latest ST-elevated
myocardial infarction (STEMI) guidelines of 2017,
they have a class 2A indication only in cases
of bailout – so in cases of no flow or thrombot-
ic complications.”
However, despite the progressive downgrade
by guidelines, the use of GPIs remain quite com-
mon in clinical practice in the setting of primary
PCI, as shown in registry data
2
.
“My position is different on this topic,” con-
tinued Dr Menozzi. “I only partially agree with the
view of guidelines. I believe that in high thrombotic-
risk patients with ACS, particularly in the setting of
STEMI, the need for intravenous antiplatelet agents
is still present. I believe that, if GPIs are used in a
modern manner, which means strongly limiting the
bleeding risk associated with these drugs, not in
the manner of 10 to 15 years ago, GPIs can guar-
antee better clinical outcomes for the patients at
high thrombotic risk. ”
Picking apart the current recommendation of
GPI use in PCI bailout, Dr Menozzi highlighted that
the value of GPIs is lowered after the complication
has occurred, compared to its value as prophy-
laxis. “I am convinced you should still use GPIs
in a provisional manner, not for every patient but
for selected patients,” he said. “In those
selected patients, you have to use these
drugs very early in the procedure, to
prevent thrombotic complications.
“You read in guidelines that GPIs
should be considered for bailout, but
there is no specific study about bailout.
So, the use of GPIs in bail-out situations
is just common sense – when you have a
disaster, you try to recover it.”
A 2013 review by Ianetta et al.
highlights the evidence supporting a
positive role of GPIs in a certain patients
subset, stating that “guidelines try in
general to address routes on the basis
of ‘one concept fits all’ which is definitely
quite impossible in clinical conditions such as
acute myocardial infarction, as STEMI or NSTEMI,
represent a spectrum of clinical situations rather
than a clear-cut pathology.”
2
Commenting on
the state of evidence regarding GPIs use in this
area, Dr Menozzi said: “The evidence on GPIs is
weak because we have no trials from the present
era. On the other hand, data against the use of
intravenous drugs are non-existent. Many authors
hypothesise that oral antiplatelet drugs we use at
present substitute the intravenous ones. But this is
not demonstrated.”
And recent evidence is not entirely lacking,
argued Dr Menozzi. A 2015 study
of the National Cardiovascular
Data Registry investigated
the effects of GPIs on
outcomes after percutane-
ous coronary intervention,
finding that in unse-
lected acute coronary
syndrome patients
undergoing, PCI, GPIs
use was associated with
reduced in-hospital mortality
and increased bleeding
3
.
“The focus is to identify
the patients who can derive the best benefit with
the lowest harm risk,” summarised Dr Menozzi.
“This is possible, because we know the char-
acteristics of the patients, and we know definite
characteristics of the drug now.
“In 2018, the use of GPIs should be driven by
a very correct patient selection, selecting for exam-
ple a patient with very large myocardial infarction,
younger in age, early presenters, patients with
symptoms occurring just within one or two hours
such that the thrombus is very fresh and can be
very easily dissolved by GPI, patients with very
large thrombus burden on angiogram, patients
with multivessel disease or cardiogenic shock: in
summary, patients with a very high ischae-
mic risk.”
He went on to stress that, to optimise
the use of GPIs, it is very important to also
manage haemorrhagic risk. “This is done
by carefully selecting the patient, using
radial access to minimise bleeding at
access site, being very careful in not
overdosing heparin, using reversal agents,
and administering a short duration infusion,
sometimes also only tirofiban bolus,” he said.
The possibility to use reversal agents is an-
other prominent difference in contem-
poraneous GPI use. In addition,
short infusion duration
can improve safety, re-
ducing bleeding risk
without affecting
efficacy, noted Dr
Menozzi, adding
that the intrave-
nously adminis-
tered GPIs can
be employed to
prevent compli-
cations during
the proce-
dure, after
which an oral
agent can
be given.
Asked
whether he fore-
sees new study
being carried
out to build a clearer
picture of where GPIs
are most appropriate,
Dr Menozzi was doubt-
ful: “There will be no
new study on the use
of GPIs in the present
era, although it would
be very welcome.
“And it would be
very interesting to see
a trial comparing, in
the setting of high risk
STEMI, a strategy of
GPIs versus no GPIs.
Clinical crossroads on optimal antithrombotic therapy in patients treated with PCI 
Parini 
Friday 
12:45
“We have progressively
seen a reduction in the
use of glycoprotein
IIb/IIIa inhibitors, and
a rapid downgrade
of the indication by
guidelines.”
Alberto Menozzi
Continued on page 6
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