Angioplasty: abciximab reduces myocardial infarction but increases major bleeding unlike eptifibatide or tirofiban

Clinical bottom line (level 2a)

  1. Patients undergoing PTCA who receive abciximab compared with placebo are less likely to have a myocardial infarction (NNT = 24 at 30 days) or urgent revascularisation (NNT = 29 at 30 days) , but more likely to have a major bleed (NNH = 53 at 30 days) .
  2. Abciximab does not clearly reduce death.
  3. Patients who receive eptifibatide or tirofiban compared with placebo are less likely to require urgent revascularisation (NNT = 53 at 30 days) .
  4. Eptifibatide or tirofiban do not clearly reduce death, myocardial infarction, nor increase major bleeding.
Brown et al: Am J Cardiol 2001; 87 : 537-541
Expires March 2004

The study

Systematic review of all randomised controlled trials of
  • Patients: undergoing percutaneous coronary intervention
  • Intervention: GP IIb/IIIa inhibitor
  • Outcome: death, myocardial infarction, urgent or emergent revascularisation, major bleeding
Articles found in ?English using Medline, (search terms: platelet inhibitors, angioplasty, stent ) and searching citation lists of review articles

Selection criteria: see above
Appraisal criteria: blinding, randomisation, placebo-controlled, intention-to-treat analysis
Articles excluded if: -

8 studies found involving 14644 patients (EPIC, EPILOG, EPISTENT, CAPTURE, RAPPORT, IMPACT-1, IMPACT-II, RESTORE)
Studies were found to be heterogenous for a composite end-point of death, MI, revascularisation, major bleeding - so results were combined using a random effects model.

The evidence

Outcome Time to outcome CER OR
(95% CI)		 NNT
(95% CI)
death: abciximab v. placebo 30 days /
(1.1%)		 0.69
(0.40 to 1.09) 		300
(NNT = 1000 to infinity;
NNH = 150 to infinity)
death: eptifibatide or tirofiban v. placebo 30 days /
(0.98%)		 0.74
(0.40 to 1.28) 		400
(NNT = 370 to infinity;
NNH = 170 to infinity)
myocardial infarction: abciximab v. placebo 30 days /
(8.5%)		 0.49
(0.40 to 0.59) 		24
(20 to 30)
myocardial infarction: eptifibatide or tirofiban v. placebo 30 days /
(6.9%)		 0.85
(0.69 to 1.04) 		100
(NNT = 390 to infinity;
NNH = 49 to infinity)
urgent revascularisation: abciximab v. placebo 30 days /
(6.2%)		 0.42
(0.34 to 0.53) 		29
(25 to 36)
urgent revascularisation: eptifibatide or tirofiban v. placebo 30 days /
(5.5%)		 0.76
(0.60 to 0.96) 		79
(47 to 480)
major bleeding: abciximab v. placebo 30 days /
(3.8%)		 1.53
(1.24 to 1.90) 		-53
(-120 to -31)
major bleeding: eptifibatide or tirofiban v. placebo 30 days /
(4.3%)		 1.19
(0.94 to 1.52) 		130
(NNT = 400 to infinity;
NNH = 48 to infinity)

Comments

  1. By limiting the search to Medline important articles may have been missed.

Citation

  1. Brown DL, Fann , Chang CJ: meta-analysis of effectiveness and safety of abciximab versus eptifibatide or tirofiban in percutaneous coronary intervention. Am J Cardiol 2001; 87 : 537-541
Search Terms: from ACP Journal Club
Contributor: Chris Ball, March 2002
Reviewer:

Clinical Question.
Patient undergoing PTCA
Intervention or Exposure abciximab, eptifibatide, tirofiban
Comparison placebo
Outcome death, myocardial infarction, urgent revascularisation, major bleeding