In Brighton we are currently using Abciximab as one of the limbs in the
Assent 111 study for thrombolysis of Acute MI. Patients are being
recruited in A&E and randomised to one of 3 limbs:
1) TNK-tpa (half dose) and Abciximab and low dose heparin
2) TNK-tpa (full dose) and Enoxaparin
3) TNK-tpa (full dose) and heparin
John Ryan
-----Original Message-----
From: John ONeill [SMTP:[log in to unmask]]
Sent: 21 September 2000 03:31
To: [log in to unmask]
Subject: Glycoprotein IIb / IIIa Inhibitors
<< File: ATT00000.htm >> The American Heart Association /American College
of Cardiology has brought
out guidelines on the use of G IIb IIIA inhibitors for non ST segment
elevation acute coronary syndromes. If taken on board in UK emergency
departments it will certainly raise our drugs bill. Is any department on
the list already using them ?
John Ryan
We are currently using a glycoprotein IIb/IIa inhibitor (Tirofiban).
However this is in the CCU setting, and almost always in patients with an
enzyme rise, which means waiting a minimum of 6 hours from start of pain
(CK MB, Trop I) and often 24 hours (Trop T). Its usually used in patients
with unstable angina at high risk of infarcting (Trop T 0.1-0.2) or in the
group with persistent pain or an enzyme rise but no ST elevation, and
almost all patients go on to have angiography as soon as possible.
I think this will limit its use in A&E, most of our patients dont start it
until 12-24hrs after admission.
Overall the data supporting the use of these agents is still not that
substantial.
They prevent platelet aggregation, and several studies have shown small but
significant improvements in outcome in MI without ST elevation, and those
with persistent ischaemia at high risk of infarcting.
In the AHA guidelines on MI management they rate the data on its use as
IIA, (conflicting evidence but supported by the weight of evidence). The
PURSUIT Trial, the largest to date showed a 1.5% reduction in death or
infarction (p=0.04), but this was almost entirely in the sub group who had
early revascularisation PTCA etc. (and the female sub group showed no
improvement at all). There was also a significant increase in bleeding
complications.
The inclusion criteria for PURSUIT were persisting ECG evidence of
ischaemia, or an enzyme rise without ST elevation which both take time to
establish, so I don't think at the moment there are many A&E patients it
would be appropriate for.
Anyone else using it?
John O Neill
Medical SHO
London
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