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Efficacy and Safety of Intracoronary versus Intravenous Administration of Tirofiban during Percutaneous Coronary Intervention for Acute Coronary Syndrome: A Meta-Analysis of Randomized Controlled Trials.

Tang X, Li R, Jing Q, Liu Y, Liu P - PLoS ONE (2015)

Bottom Line: Percutaneous coronary intervention (PCI) is known as the most effective treatment for acute coronary syndrome (ACS).To date, there has been no comprehensive evaluation of the efficacy and safety of intracoronary (IC) tirofiban administration for ACS patients undergoing PCI compared with intravenous (IV) administration.However, there was no statistically significant difference in the risk of bleeding complications between the two groups.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, The first hospital of QinHuangDao, QinHuangDao, HeBei, China.

ABSTRACT

Background: Percutaneous coronary intervention (PCI) is known as the most effective treatment for acute coronary syndrome (ACS). However, without proper therapy and patient management, stent thrombosis after PCI may lead to another myocardial infarction. In addition to aspirin and clopidogrel, tirofiban is often used as an antiplatelet therapy in patients with ACS. To date, there has been no comprehensive evaluation of the efficacy and safety of intracoronary (IC) tirofiban administration for ACS patients undergoing PCI compared with intravenous (IV) administration. Therefore, this meta-analysis was conducted to investigate the clinical efficiency and safety of IC versus intravenous (IV) tirofiban in ACS patients undergoing PCI.

Methods: We searched PubMed and Medline for randomized controlled trials (RCTs) comparing IC versus IV administration of tirofiban in ACS patients undergoing PCI. We evaluated the effects of tirofiban on thrombolysis in myocardial infarction (TIMI) grade 3 flow after PCI, TIMI myocardial perfusion grade 3 (TMP grade 3), left ventricular ejection fraction (LVEF), major adverse cardiovascular events (MACE), target vessel revascularization (TVR), death, reinfarction and adverse drug effects (specifically bleeding events).

Results: Seven trials involving 1,027 patients were included in this meta-analysis. IC administration of tirofiban significantly increased TIMI grade 3 flow (OR 2.11; 95% CI 1.02 to 4.37; P = 0.04) and TMP grade 3 (OR 2.67; 95% CI 1.09 to 6.49; P = 0.03, I2 = 64%) while reducing MACE (OR 0.46, 95% CI: 0.28 to 0.75; P = 0.002) compared with IV administration of tirofiban. No significant differences were observed in the occurrence of TVR, death, reinfarction and the incidence of bleeding events between the two groups.

Conclusions: This meta-analysis supports the use of IC over IV administration of tirofiban in patients with ACS to improve TIMI flow, TMP flow and MACE. However, there was no statistically significant difference in the risk of bleeding complications between the two groups.

No MeSH data available.


Related in: MedlinePlus

Forest plot of LVEF in ACS patients with IC vs. IV administration of tirofiban.(A). Forest plot for in-hospital LVEF based on a random-effects model in ACS patients with IC vs. IV administration of tirofiban. (B). Forest plot for LVEF over a medium-term follow-up, based on a random-effects model in ACS patients with IC vs. IV administration of tirofiban. (C). Funnel plot of in-hospital LVEF used to identify evidence of publication bias. (D). Funnel plot of LVEF over a medium-term follow-up used to identify evidence of publication bias.
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pone.0129718.g004: Forest plot of LVEF in ACS patients with IC vs. IV administration of tirofiban.(A). Forest plot for in-hospital LVEF based on a random-effects model in ACS patients with IC vs. IV administration of tirofiban. (B). Forest plot for LVEF over a medium-term follow-up, based on a random-effects model in ACS patients with IC vs. IV administration of tirofiban. (C). Funnel plot of in-hospital LVEF used to identify evidence of publication bias. (D). Funnel plot of LVEF over a medium-term follow-up used to identify evidence of publication bias.

Mentions: All of the included trials [29–35] reported the effects of IC versus IV administration of tirofiban after complete perfusion (TIMI grade 3 flow) following PCI. Five trials reported the effect of IC versus IV administration of tirofiban on TMP grade 3[29–31,33,35] and in-hospital LVEF [29,30,32–34]. The pooled results showed a significant difference in complete perfusion and TMP grade 3 after PCI as well as LVEF in in-hospital patients with ACS undergoing PCI who received IC tirofiban versus controls who received IV administration. Compared with IV tirofiban, IC tirofiban significantly increased the frequency of complete perfusion (OR 2.11; 95% CI 1.02 to 4.37; P = 0.04, I2 = 61%) and TMP grade 3 (OR 2.67; 95% CI 1.09 to 6.49; P = 0.03, I2 = 64%) after PCI based on a random-effects model (Fig 3). In other words, IC tirofiban was able to significantly decrease the frequency of the ‘no-reflow’ and ‘slow-flow’ phenomena after PCI. Funnel plot analysis of 7 included trials addressing complete perfusion and 5 included trials addressing TMP grade 3 did not suggest the presence of publication bias (Fig 3C and 3D). Although pooled analysis with a random-effects model also showed a significant difference in in-hospital LVEF between the two groups (MD 2.77; 95% CI 0.16 to 5.38; P = 0.04, I2 = 64%) (Fig 4A), the outcome of the analysis with a random-effects model [30,33–35] did not reveal any significant difference in LVEF over a relatively medium-term follow-up (30 days to 9 months) (MD 3.02; 95% CI -0.36 to 6.40; P = 0.08, I2 = 90%) (Fig 4B), and the associated Funnel plot analysis did not suggest the presence of publication bias (Fig 4C and 4D). Compared with IV administration, the overall outcomes from 5 of the included RCTs [29,30,32,34,35] based on a fixed-effects model suggested that IC tirofiban was associated with a relative reduction in MACE between the two groups of 54% (OR 0.46, 95% CI: 0.28 to 0.75; P = 0.002, I2 = 21%) (Fig 5A), and the outcome data were similar to the above outcome from 4 of the included trials [29,30,34,35] (OR 0.39, 95% CI: 0.23 to 0.67; P = 0.0005, I2 = 0%) (Fig 5B), with the exception of one retrospective study (32). Again, the outcomes regarding MACE according to a random-effects model were consistent with the above main analyses. Funnel plot analysis of 5 of the included trials addressing MACE did not suggest the presence of publication bias (Fig 5C).


Efficacy and Safety of Intracoronary versus Intravenous Administration of Tirofiban during Percutaneous Coronary Intervention for Acute Coronary Syndrome: A Meta-Analysis of Randomized Controlled Trials.

Tang X, Li R, Jing Q, Liu Y, Liu P - PLoS ONE (2015)

Forest plot of LVEF in ACS patients with IC vs. IV administration of tirofiban.(A). Forest plot for in-hospital LVEF based on a random-effects model in ACS patients with IC vs. IV administration of tirofiban. (B). Forest plot for LVEF over a medium-term follow-up, based on a random-effects model in ACS patients with IC vs. IV administration of tirofiban. (C). Funnel plot of in-hospital LVEF used to identify evidence of publication bias. (D). Funnel plot of LVEF over a medium-term follow-up used to identify evidence of publication bias.
© Copyright Policy
Related In: Results  -  Collection

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Show All Figures
getmorefigures.php?uid=PMC4465926&req=5

pone.0129718.g004: Forest plot of LVEF in ACS patients with IC vs. IV administration of tirofiban.(A). Forest plot for in-hospital LVEF based on a random-effects model in ACS patients with IC vs. IV administration of tirofiban. (B). Forest plot for LVEF over a medium-term follow-up, based on a random-effects model in ACS patients with IC vs. IV administration of tirofiban. (C). Funnel plot of in-hospital LVEF used to identify evidence of publication bias. (D). Funnel plot of LVEF over a medium-term follow-up used to identify evidence of publication bias.
Mentions: All of the included trials [29–35] reported the effects of IC versus IV administration of tirofiban after complete perfusion (TIMI grade 3 flow) following PCI. Five trials reported the effect of IC versus IV administration of tirofiban on TMP grade 3[29–31,33,35] and in-hospital LVEF [29,30,32–34]. The pooled results showed a significant difference in complete perfusion and TMP grade 3 after PCI as well as LVEF in in-hospital patients with ACS undergoing PCI who received IC tirofiban versus controls who received IV administration. Compared with IV tirofiban, IC tirofiban significantly increased the frequency of complete perfusion (OR 2.11; 95% CI 1.02 to 4.37; P = 0.04, I2 = 61%) and TMP grade 3 (OR 2.67; 95% CI 1.09 to 6.49; P = 0.03, I2 = 64%) after PCI based on a random-effects model (Fig 3). In other words, IC tirofiban was able to significantly decrease the frequency of the ‘no-reflow’ and ‘slow-flow’ phenomena after PCI. Funnel plot analysis of 7 included trials addressing complete perfusion and 5 included trials addressing TMP grade 3 did not suggest the presence of publication bias (Fig 3C and 3D). Although pooled analysis with a random-effects model also showed a significant difference in in-hospital LVEF between the two groups (MD 2.77; 95% CI 0.16 to 5.38; P = 0.04, I2 = 64%) (Fig 4A), the outcome of the analysis with a random-effects model [30,33–35] did not reveal any significant difference in LVEF over a relatively medium-term follow-up (30 days to 9 months) (MD 3.02; 95% CI -0.36 to 6.40; P = 0.08, I2 = 90%) (Fig 4B), and the associated Funnel plot analysis did not suggest the presence of publication bias (Fig 4C and 4D). Compared with IV administration, the overall outcomes from 5 of the included RCTs [29,30,32,34,35] based on a fixed-effects model suggested that IC tirofiban was associated with a relative reduction in MACE between the two groups of 54% (OR 0.46, 95% CI: 0.28 to 0.75; P = 0.002, I2 = 21%) (Fig 5A), and the outcome data were similar to the above outcome from 4 of the included trials [29,30,34,35] (OR 0.39, 95% CI: 0.23 to 0.67; P = 0.0005, I2 = 0%) (Fig 5B), with the exception of one retrospective study (32). Again, the outcomes regarding MACE according to a random-effects model were consistent with the above main analyses. Funnel plot analysis of 5 of the included trials addressing MACE did not suggest the presence of publication bias (Fig 5C).

Bottom Line: Percutaneous coronary intervention (PCI) is known as the most effective treatment for acute coronary syndrome (ACS).To date, there has been no comprehensive evaluation of the efficacy and safety of intracoronary (IC) tirofiban administration for ACS patients undergoing PCI compared with intravenous (IV) administration.However, there was no statistically significant difference in the risk of bleeding complications between the two groups.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, The first hospital of QinHuangDao, QinHuangDao, HeBei, China.

ABSTRACT

Background: Percutaneous coronary intervention (PCI) is known as the most effective treatment for acute coronary syndrome (ACS). However, without proper therapy and patient management, stent thrombosis after PCI may lead to another myocardial infarction. In addition to aspirin and clopidogrel, tirofiban is often used as an antiplatelet therapy in patients with ACS. To date, there has been no comprehensive evaluation of the efficacy and safety of intracoronary (IC) tirofiban administration for ACS patients undergoing PCI compared with intravenous (IV) administration. Therefore, this meta-analysis was conducted to investigate the clinical efficiency and safety of IC versus intravenous (IV) tirofiban in ACS patients undergoing PCI.

Methods: We searched PubMed and Medline for randomized controlled trials (RCTs) comparing IC versus IV administration of tirofiban in ACS patients undergoing PCI. We evaluated the effects of tirofiban on thrombolysis in myocardial infarction (TIMI) grade 3 flow after PCI, TIMI myocardial perfusion grade 3 (TMP grade 3), left ventricular ejection fraction (LVEF), major adverse cardiovascular events (MACE), target vessel revascularization (TVR), death, reinfarction and adverse drug effects (specifically bleeding events).

Results: Seven trials involving 1,027 patients were included in this meta-analysis. IC administration of tirofiban significantly increased TIMI grade 3 flow (OR 2.11; 95% CI 1.02 to 4.37; P = 0.04) and TMP grade 3 (OR 2.67; 95% CI 1.09 to 6.49; P = 0.03, I2 = 64%) while reducing MACE (OR 0.46, 95% CI: 0.28 to 0.75; P = 0.002) compared with IV administration of tirofiban. No significant differences were observed in the occurrence of TVR, death, reinfarction and the incidence of bleeding events between the two groups.

Conclusions: This meta-analysis supports the use of IC over IV administration of tirofiban in patients with ACS to improve TIMI flow, TMP flow and MACE. However, there was no statistically significant difference in the risk of bleeding complications between the two groups.

No MeSH data available.


Related in: MedlinePlus