Angioplasty: stenting: using abciximab led to fewer myocardial infarctions but more thrombocytopenia than tirofiban

Clinical bottom line (level 1b)

  1. Patients undergoing coronary artery stenting who received tirofiban compared with abciximab were more likely to die, have a myocardial infarction or require urgent revascularisation (NNH = 63 at 30 days) .
  2. Patient who received tirofiban were more likely to have a myocardial infarction (NNH = 67 at 30 days) .
  3. Patients who received tirofiban were less likely to develop thrombocytopenia (NNT = 52 at 30 days) , but not clearly less likely to have a major bleed.
Topol et al: New Engl J Med 2001; 344 : 1888-1894
Expires March 2004

The study

Double-blinded concealed randomised trial without intention-to-treat
Setting: 148 hospitals in 18 countries in North America and Europe

5308 patients (aged mean 62, 74% male) scheduled to undergo coronary stenting (for vessels with > 70% stenosis)

Excluded if
  • ongoing bleeding, or bleeding diathesis including platelet count < 120 x 10 9 /l
  • serum creatinine > 220 micromol/l
  • cardiogenic shock or acute myocardial infarction with ST elevation

Control Group: (n = 2661, 2411 analysed): abciximab bolus 0.25 mg/kg followed by and infusion of 0.125 microg/kg/min (max 10 microg/min) for 12 hours
Experimental Group: (n = 2647, 2398 analysed): tirofiban bolus 10 microg/kg followed by an infusion of 0.15 microg/kg/min for 18 to 24 hours
All patients received 250 to 500 mg aspirin before the procedure and when possible a loading dose of clopidogrel 300 mg 2 to 6 hours before the procedure. Aspirin 75 to 325 mg daily and clopidogrel 75 mg daily were continued for 30 days. Heparin was administered at the start of the procedure at no more than 70 units/kg with a target activated clotting time of 250 s.
91% followed for 30 days
Outcome notes:
  • thrombocytopenia : platelet count < 100 x 109/l

The evidence

Outcome Time to outcome CER EER RRR
(95% CI)		 ARR
(95% CI)		 NNT
(95% CI)
death, non-fatal myocardial infarction, urgent revascularisation 30 days 145
(6.01%)		 182
(7.59%)		 -26%
(-56% to -2%)		 -1.58%
(-3.00% to -0.153%)		 -63
(-650 to -33)
myocardial infarction 30 days 130
(5.39%)		 165
(6.88%)		 -28%
(-59% to -2%)		 -1.49%
(-2.84% to -0.13%)		 -67
(-750 to -35)
major bleeding 30 days 17
(0.71%)		 22
(0.92%)		 -30%
(-140% to 31%)		 -0.21%
(-0.72% to 0.29%)		 -470
(NNT = 130 to infinity;
NNH = 340 to infinity)
thrombocytopenia 30 days 58
(2.41%)		 12
(0.50%)		 79%
(61% to 89%)		 1.91%
(1.23% to 2.58%)		 52
(39 to 81)

Comments

  1. Patients were stratified for diabetes before randomisation.

Citation

  1. Topol EJ, Moliterno DJ, Herrmann HC, et al: comparison of two platelet glycoprotein IIb/IIIa inhibitors tirofiban and abciximab for the prevention of ischemic events with percutaneous coronary revascularization (TARGET). New Engl J Med 2001; 344 : 1888-1894
Search Terms: from ACP Journal Club
Contributor: Chris Ball, March 2002
Reviewer:

Clinical Question.
Patient angioplasty coronary stenting
Intervention or Exposure tirofiban
Comparison abciximab
Outcome death, myocardial infarction, urgent revascularisation