ORIGINAL ARTICLE
Heart, Lung and Circulation (2015) 24, 1062–1067 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2015.04.161
Effect of Intracoronary Plus Low-Dose Intravenous Tirofiban in Elderly Patients with Acute Myocardial Infarction Qiang Zhao, MD, PhD a, Yun He, MD a, Shu-Xiang Wang, MD a, Biao Li, MD a, Yuan-Jie Xu, MD a, Jing-Yun Luo, MD, PhD a, Wei-Guang Huang, MD a, Tong-Guo Wu, MD a*, Le-Xin Wang, FCSANZ b* a
Department of Cardiology, the Red Cross Hospital of Guangzhou City, the Fourth Affiliated Hospital of Jinan University, Guangzhou 510220, PR China School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW 2678, Australia
b
Received 4 January 2015; received in revised form 6 April 2015; accepted 8 April 2015; online published-ahead-of-print 7 May 2015
Background
To investigate the efficacy and safety of low-dose tirofiban in elderly patients undergoing primary percutaneous coronary intervention (PPCI) for acute myocardial infarction (AMI).
Methods
One hundred and four patients aged 70 years and above undergoing PPCI for AMI were divided into control (n=52) and study (n=52) groups. All patients received bolus intracoronary injection of tirofiban (10 mg/kg), which was followed by intravenous infusion at 0.15 mg/kg/min in the control group and at 0.075 mg/kg/min in the study group for 24 h.
Results
There was no statistically significant difference between the study group and the control group in patients with complete ST segment resolution (84.2% vs. 85.7%, P = 0.851), peak high-sensitive cardiac troponin T level (5.11.9 vs. 5.82.6 mg/L, P = 0.123), scores of thrombus in the infarct-related artery (0.980.51 vs. 1.12 0.59, P = 0.214), and patients with TIMI grade 3 flow (86.0% vs. 88.2%, P=0.737) after PPCI. There were no statistically significant differences between the two groups in left ventricular ejection fraction (57.16.3 vs. 57.76.1, P=0.611) and composite major adverse cardiovascular events rate (P =0.778) at 90 days after PCI. The total bleeding rate in the study group was lower than in the control group (P = 0.048).
Conclusion
In elderly patients with AMI undergoing primary PCI, low and standard dose of tirofiban exerts similar effects on platelet aggregation, coronary flow, infarct size, left ventricular systolic function and short-term clinical outcomes. Low dose regimen is associated with a lower bleeding rate than the standard dose.
Keywords
Acute myocardial infarction Percutaneous coronary intervention Tirofiban Adverse cardiac events Coronary artery disease
Introduction Primary percutaneous coronary intervention (PPCI) is the preferred method of treatment for patients with acute myocardial infarction (AMI) due to improved myocardial
perfusion, decreased infarct size, and improved clinical prognosis compared with pharmacological reperfusion [1,2]. Rupture of vulnerable plaque occuring in patients with AMI or during PPCI, induces platelet aggregation and acute stent thrombosis [3]. However, the optimum strategy for
*Corresponding authors at: Prof Lexin Wang, School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW 2678, Australia. Tel.: +61 2 69332905; fax: +61 2 69332587 or Prof Tong-Guo Wu, Department of Cardiology, the Red Cross Hospital of Guangzhou City, Guangdong Province, PR China 510220. Tel.: +86 020-34403785, Emails: [email protected] (T.-G. Wu), [email protected] (L.-X. Wang) © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
1063
Tirofiban in elderly patients with AMI
adjunctive antiplatelet pharmacotherapy in PPCI remains an unresolved issue [4]. Activation of the platelet glycoprotein (GP) IIb/IIIa receptor is the final pathway of platelet aggregation. As a result, GP IIb/IIIa inhibitors (GPIs) are commonly used in patients with non-ST-elevation (NSTEMI) [1] or STelevation myocardial infarction (STEMI) [2] undergoing PPCI. Tirofiban is recommended in AMI patients treated with PPCI. In our previous study on patients with acute coronary syndrome undergoing PPCI, intracoronary bolus dose of tirofiban is better than intravenous bolus administration for improving coronary flow, myocardial perfusion and decreasing composite 30-day major adverse cardiac events (MACE) rate [5]. At present, intracoronary or intravenous administration of tirofiban is acceptable [6]. The plasma half-life of tirofiban is about two hours, so continuous intravenous infusion is needed for sustained platelet inhibition [7]. Intense antithrombotic treatment and early revascularisation increased the risk of bleeding in acute coronary syndrome (ACS) patients, and major bleeding closely associated with higher risk of death, especially among elderly patients [8]. However, few studies have been conducted to investigate the optimal maintenance dosing of tirofiban in elderly patients. The aim of this study is to evaluate the safety and efficacy of low maintenance dose of tirofiban in elderly (greater than or equal to 70 years) patients with AMI who underwent PPCI.
Methods
committee of the Guangzhou Red Cross Hospital. Written informed consent was given by all patients before the study. Between January 2011 and February 2014, 104 patients (60 males, average age 75.53.9 years) were enrolled in this single-centre, open-label randomised study; 81 patients had STEMI and 23 had NSTEMI (Table 1). The patients were selected from 520 patients consecutively referred for AMI management. Patients were considered eligible if they matched with all of the following inclusion criteria: (1) angina no more than 12 h prior to admission; (2) 70 years old; (3) ST-segment changes in two adjacent electrocardiogram leads or more; and (4) serum high-sensitive cardiac troponin T (hs-cTnT) elevation. Patients who fulfilled any one of the following criteria were excluded from this study: (1) systolic BP
Heart, Lung and Circulation (2015) 24, 1062–1067 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2015.04.161
Effect of Intracoronary Plus Low-Dose Intravenous Tirofiban in Elderly Patients with Acute Myocardial Infarction Qiang Zhao, MD, PhD a, Yun He, MD a, Shu-Xiang Wang, MD a, Biao Li, MD a, Yuan-Jie Xu, MD a, Jing-Yun Luo, MD, PhD a, Wei-Guang Huang, MD a, Tong-Guo Wu, MD a*, Le-Xin Wang, FCSANZ b* a
Department of Cardiology, the Red Cross Hospital of Guangzhou City, the Fourth Affiliated Hospital of Jinan University, Guangzhou 510220, PR China School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW 2678, Australia
b
Received 4 January 2015; received in revised form 6 April 2015; accepted 8 April 2015; online published-ahead-of-print 7 May 2015
Background
To investigate the efficacy and safety of low-dose tirofiban in elderly patients undergoing primary percutaneous coronary intervention (PPCI) for acute myocardial infarction (AMI).
Methods
One hundred and four patients aged 70 years and above undergoing PPCI for AMI were divided into control (n=52) and study (n=52) groups. All patients received bolus intracoronary injection of tirofiban (10 mg/kg), which was followed by intravenous infusion at 0.15 mg/kg/min in the control group and at 0.075 mg/kg/min in the study group for 24 h.
Results
There was no statistically significant difference between the study group and the control group in patients with complete ST segment resolution (84.2% vs. 85.7%, P = 0.851), peak high-sensitive cardiac troponin T level (5.11.9 vs. 5.82.6 mg/L, P = 0.123), scores of thrombus in the infarct-related artery (0.980.51 vs. 1.12 0.59, P = 0.214), and patients with TIMI grade 3 flow (86.0% vs. 88.2%, P=0.737) after PPCI. There were no statistically significant differences between the two groups in left ventricular ejection fraction (57.16.3 vs. 57.76.1, P=0.611) and composite major adverse cardiovascular events rate (P =0.778) at 90 days after PCI. The total bleeding rate in the study group was lower than in the control group (P = 0.048).
Conclusion
In elderly patients with AMI undergoing primary PCI, low and standard dose of tirofiban exerts similar effects on platelet aggregation, coronary flow, infarct size, left ventricular systolic function and short-term clinical outcomes. Low dose regimen is associated with a lower bleeding rate than the standard dose.
Keywords
Acute myocardial infarction Percutaneous coronary intervention Tirofiban Adverse cardiac events Coronary artery disease
Introduction Primary percutaneous coronary intervention (PPCI) is the preferred method of treatment for patients with acute myocardial infarction (AMI) due to improved myocardial
perfusion, decreased infarct size, and improved clinical prognosis compared with pharmacological reperfusion [1,2]. Rupture of vulnerable plaque occuring in patients with AMI or during PPCI, induces platelet aggregation and acute stent thrombosis [3]. However, the optimum strategy for
*Corresponding authors at: Prof Lexin Wang, School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW 2678, Australia. Tel.: +61 2 69332905; fax: +61 2 69332587 or Prof Tong-Guo Wu, Department of Cardiology, the Red Cross Hospital of Guangzhou City, Guangdong Province, PR China 510220. Tel.: +86 020-34403785, Emails: [email protected] (T.-G. Wu), [email protected] (L.-X. Wang) © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
1063
Tirofiban in elderly patients with AMI
adjunctive antiplatelet pharmacotherapy in PPCI remains an unresolved issue [4]. Activation of the platelet glycoprotein (GP) IIb/IIIa receptor is the final pathway of platelet aggregation. As a result, GP IIb/IIIa inhibitors (GPIs) are commonly used in patients with non-ST-elevation (NSTEMI) [1] or STelevation myocardial infarction (STEMI) [2] undergoing PPCI. Tirofiban is recommended in AMI patients treated with PPCI. In our previous study on patients with acute coronary syndrome undergoing PPCI, intracoronary bolus dose of tirofiban is better than intravenous bolus administration for improving coronary flow, myocardial perfusion and decreasing composite 30-day major adverse cardiac events (MACE) rate [5]. At present, intracoronary or intravenous administration of tirofiban is acceptable [6]. The plasma half-life of tirofiban is about two hours, so continuous intravenous infusion is needed for sustained platelet inhibition [7]. Intense antithrombotic treatment and early revascularisation increased the risk of bleeding in acute coronary syndrome (ACS) patients, and major bleeding closely associated with higher risk of death, especially among elderly patients [8]. However, few studies have been conducted to investigate the optimal maintenance dosing of tirofiban in elderly patients. The aim of this study is to evaluate the safety and efficacy of low maintenance dose of tirofiban in elderly (greater than or equal to 70 years) patients with AMI who underwent PPCI.
Methods
committee of the Guangzhou Red Cross Hospital. Written informed consent was given by all patients before the study. Between January 2011 and February 2014, 104 patients (60 males, average age 75.53.9 years) were enrolled in this single-centre, open-label randomised study; 81 patients had STEMI and 23 had NSTEMI (Table 1). The patients were selected from 520 patients consecutively referred for AMI management. Patients were considered eligible if they matched with all of the following inclusion criteria: (1) angina no more than 12 h prior to admission; (2) 70 years old; (3) ST-segment changes in two adjacent electrocardiogram leads or more; and (4) serum high-sensitive cardiac troponin T (hs-cTnT) elevation. Patients who fulfilled any one of the following criteria were excluded from this study: (1) systolic BP
