Angina: glycoprotein IIb/IIIa inhibitors reduce death and myocardial infarction, but increase bleeding in PTCA and unstable angina

Clinical bottom line (level 1a)

  1. Patients undergoing PTCA who receive a glycoprotein IIb/IIIa inhibitor compared with standard medical therapy are less likely to die or have a myocardial infarction (NNT = 45 at 6 months) or require urgent revascularisation (NNT = 40 at 6 months) , but are more likely to have major bleeding (NNH = 58 at 30 days) .
  2. Patients undergoing PTCA and stenting, who receive a glycoprotein IIb/IIIa inhibitor compared with standard medical therapy, are less likely to die or have a myocardial infarction (NNT = 22 at 6 months) , or require urgent revascularisation (NNT = 130 at 6 months) , but not clearly more likely to have major bleeding.
  3. Patients with unstable angina or a non-ST elevation myocardial infarction who receive a glycoprotein IIb/IIIa inhibitor compared with standard therapy are less likely to die or have a myocardial infarction (NNT = 65 at 6 months) , but more likely to have major bleeding (NNH = 110 at 6 months) .
Bosch and Marrugat: Cochrane Library 2001; 4 : -
Expires April 2004

The study

Systematic review of all randomised controlled trials of
  • Patients: undergoing percutaneous coronary revascularisation, or with unstable angina or non-ST-elevation myocardial infarction
  • Intervention: iv glycoprotein IIb/IIIa blockers (abciximab, eptifibatide, lamifiban and tirofiban) compared with standard medical therapy
  • Outcome: death, myocardial infarction, bleeding, urgent revascularisation
Articles found in all languages using Cochrane Library, Medline, Embase, 1966 to June 2001 (search terms: detailed in text ) and searching reference lists of articles, medical websites, handsearching abstracts from cardiology conferences and contacting experts in the field and principle trial investigators.

Selection criteria: by 2 independent reviewers using the above criteria. Differences were resolved by discussion.
Appraisal criteria: by 2 independent reviewers: based pm randomisation, blinding, loss to follow-up
Articles excluded if:
  • patients aged < 18


27 articles found on 22 trials
  • 9 involving 29920 patients with unstable angina/non-ST elevation MI
  • 18 involving 12398 patients undergoing PTCA, and 5389 patients undergoing PTCA with stenting

Some analyses for PTCA, particularly involving urgent revascularisation and major bleeding were found to be heterogeneous, reflecting inconsistencies in defining these outcomes. A random-effects model was used in these cases.

The evidence

Outcome Time to outcome CER OR
(95% CI)		 NNT
(95% CI)
PTCA with stenting: death or myocardial infarction 30 days 219/2255
(9.7%)		 0.54
(0.44 to 0.67) 		24
(19 to 33)
PTCA with stenting: death or myocardial infarction 6 months 236/2055
(11.5%)		 0.57
(0.47 to 0.70) 		22
(17 to 32)
PTCA with stenting: death 6 months 48/2055
(2.3%)		 0.55
(0.35 to 0.86) 		96
(66 to 310)
PTCA with stenting: urgent revascularisation 30 days 47/2255
(2.1%)		 0.62
(0.39 to 0.97) 		130
(79 to 1600)
PTCA with stenting: major bleeding 30 days 15/2184
(0.69%)		 1.43
(0.75 to 2.72) 		-340
(NNT = 86 to infinity;
NNH = 590 to infinity)
PTCA: death or myocardial infarction 30 days 414/5009
(8.3%)		 0.64
(0.56 to 0.74) 		36
(29 to 50)
PTCA: death or myocardial infarction 6 months 293/2642
(11.1%)		 0.78
(0.65 to 0.94) 		45
(28 to 170)
PTCA: urgent revascularisation 30 days 283/5009
(5.6%)		 0.56
(0.47 to 0.68) 		42
(34 to 58)
PTCA: urgent revascularisation 6 months 540/2642
(20.4%)		 0.85
(0.74 to 0.97) 		40
(22 to 200)
PTCA: major bleeding 30 days 217/4989
(4.3%)		 1.42
(1.20 to 1.67) 		-58
(-120 to -37)
angina: death or myocardial infarction 30 days 1558/13274
(11.7%)		 0.91
(0.85 to 0.98) 		110
(63 to 480)
angina: death or myocardial infarction 6 months 1302/8891
(14.6%)		 0.88
(0.81 to 0.95) 		65
(41 to 160)
angina: major bleeding 30 days 477/13231
(3.6%)		 1.26
(1.12 to 1.43) 		-110
(-240 to -68)

Comments

  1. Glycoprotein IIb/IIIa blockers did not clearly reduce mortality in patients undergoing PTCA, nor in patients with unstable angina or non-ST elevation MI.

Citation

  1. Bosch X, and Marrugat J: platelet glycoprotein IIb/IIIa blockers for percutaneous coronary revascularisation and unstable angina and non-ST-segement elevation myocardial infarction. Cochrane Library 2001; 4 : -
Search Terms: from ACP Journal Club
Contributor: Chris Ball, April 2002
Reviewer:

Clinical Question.
Patient undergoing PTCA or with unstable angina
Intervention or Exposure glycoprotein IIb/IIIa platelet inhibitors
Outcome death, myocardial infarction, urgent revascularisation, bleeding