>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.
Why not? Sorry, don't mean to sound critical, but is this protocol,
or for an other reason?
>Overall the data supporting the use of these agents is still not
>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
>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.
I have to say that I think we see plenty of patients in A&E who would
fulfill these criteria.
Royal Sussex County Hospital
[log in to unmask]