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Heart. 2007 October; 93(10): 1293.
PMCID: PMC2000953

Effects of glycoprotein IIb/IIIa blockers

To the Editor: The meta‐analysis by Hernandez et al1 showed that the reduction of death or non‐fatal myocardial infarction with IIb/IIIa inhibitors in patients with an acute coronary syndrome (ACS) was independent of patient age. The trials included were performed before widespread administration of clopidogrel in ACS.

Clopidogrel has been shown to be beneficial in ACS; its administration is a class I recommendation.2 Glycoprotein IIb/IIIa inhibition is a class I recommendation only in patients with planned percutaneous coronary intervention (PCI) in the absence of clopidogrel, but is a class IIa recommendation in patients already treated with clopidogrel.2

An analysis of the National Registry of Myocardial Infarction‐4 suggested that routinely giving a glycoprotein IIb/IIIa inhibitor to patients with a non‐ST‐elevation ACS treated with clopidogrel might not be justified, especially if PCI were not performed.3 This may be particularly true in elderly patients, since virtually all studies indicate that elderly patients are more likely to bleed than younger patients; bleeding has been shown to be an independent predictor of mortality in both ACS and PCI patients.4

An analysis of the ISAR‐REACT 2 trial showed that abciximab did not reduce the 30‐day incidence of death or any other component of major adverse cardiac events in older patients with a non‐ST‐elevation ACS treated with clopidogrel; in fact, it seemed to be harmful.5 We are currently analysing the relationship between age and outcome in three other ISAR studies.

In conclusion, while we applaud the excellent analysis of the authors, we caution that the results of their meta‐analysis may not be generalisable to all patients with ACS, particularly the elderly pretreated with clopidogrel.

Footnotes

Competing interests: None declared.

References

1. Hernández A V, Westerhout C M, Steyerberg E W. et al Effects of platelet glycoprotein IIb/IIIa receptor blockers in non‐ST segment elevation acute coronary syndromes: benefit and harm in different age subgroups. Heart 2007. 93450–455.455 [PMC free article] [PubMed]
2. Braunwald E, Antman E M, Beasley J W. et al and American College of Cardiology. American Heart Association, Committee on the Management of Patients With Unstable Angina. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non‐ST‐segment elevation myocardial infarction: summary article, a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). Circulation 2002. 1061893–1900.1900 [PubMed]
3. Bromberg‐Marin G, Marin‐Neto J A, Parsons L S. et al National Registry of Myocardial Infarction‐4. Effectiveness and safety of glycoprotein IIb/IIIa inhibitors and clopidogrel alone and in combination in non‐ST‐segment elevation myocardial infarction (from the National Registry of Myocardial Infarction‐4). Am J Cardiol 2006. 981125–1131.1131 [PubMed]
4. Kinnaird T D, Stabile E, Mintz G S. et al Incidence, predictors, and prognostic implications of bleeding and blood transfusion following percutaneous coronary interventions. Am J Cardiol 2003. 92930–935.935 [PubMed]
5. Ndrepepa G, Kastrati A, Mehilli J. et al Age‐dependent effect of abciximab in patients with acute coronary syndromes treated with percutaneous coronary intervention. Circulation 2006. 1142040–2046.2046 [PubMed]

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