Treating high-risk acute coronary syndrome (ACS) patients with an anti-platelet medicine, known as a glycoprotein (GP) IIb-IIIa inhibitor, before interventional procedures such as angioplasty significantly reduced the in-hospital incidence of combined death or subsequent heart attacks, according to research data collected from CRUSADE, a national quality improvement initiative that retrospectively examines the treatment of high-risk chest pain disorder patients at hospitals in the United States.
CRUSADE is led by the Duke Clinical Research Institute (DCRI) and funded by Millennium Pharmaceuticals Inc and Schering-Plough Corporation.
Although the benefit of GP IIb-IIIa inhibitors has been recognized for several years, these new data refine the understanding of how the timing of treatment may have a significant impact on patient health.
"The data are significant because they suggest that earlier use of GP IIb- IIIa inhibitors -- before the patient is taken to the catheterization lab -- could directly improve patient outcomes," said Matthew Roe, of the DCRI, a CRUSADE Principal Investigator and study co-author.
In this project, Dr. Adam Greenbaum, associate director, Cardiac Catheterization Laboratory at the Henry Ford Heart and Vascular Institute, and colleagues from nine other institutions analyzed the CRUSADE database for outcomes of patients admitted for high-risk chest pain disorders collectively known as non-ST-segment elevation acute coronary syndromes based on the timing of GP IIb-IIIa inhibitor initiation. After adjusting for various risk factors, the authors concluded that using a GP IIb-IIIa inhibitor "upstream," or before a patient is taken to the catheterization lab, reduced the risk of combined acute, in-hospital death or subsequent heart attack by approximately 14 percent (p<0.05).
Of the 40,979 patients in the CRUSADE database at the time of the project, 5,971 underwent PCI within 48 hours of admission. Of those patients, 2,191 (37 per cent) were treated with a GP IIb-IIIa inhibitor before being taken to the catheterization lab, and 3,780 (63 percent) were given a GP IIb-IIIa inhibitor at the time of the procedure. The in-hospital incidence of death and combined death or reinfarction stratified by timing of GP IIb-IIIa inhibition was 1.32 percent for patients who received a GP IIb-IIIa inhibitor early "upstream" compared to 1.53 percent for patients receiving a GP IIb-IIIa inhibitor in the catheterization lab.
While the results of this analysis are consistent with previous results of randomized clinical trials, the use of a GP IIb-IIIa inhibitor before catheterization or PCI remains low. GP IIb-IIIa inhibitor use prior to catheterization or PCI has a I-A recommendation, signifying the highest level of supportive evidence, from the American College of Cardiology/America Heart Association (ACC/AHA) NSTE ACS Guidelines for use of GP IIb-IIIa inhibitors in patients for whom PCI is planned.
CRUSADE (Can Rapid risk Stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) is a national quality improvement initiative designed to improve adherence to ACC/AHA guidelines for care of patients with NSTE ACS at up to 600 hospitals across the U.S. Aggregate data regarding the treatment, procedures, and medications received by patients with this diagnosis are retroactively collected and analyzed by DCRI, an academic research organization affiliated with Duke University Medical Center. Each CRUSADE site receives feedback and advice and tools for implementing changes to improve patient care.
Integrilin is indicated for the treatment of patients with acute coronary syndrome (unstable angina/non-ST-segment myocardial infarction), including patients who are to be managed medically and those undergoing percutaneous coronary intervention (PCI). It is also indicated in the United States for the treatment of patients at time of PCI, including in patients undergoing intracoronary stenting.