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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 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%