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(Circulation. 2009;119:3215-3222.)
© 2009 American Heart Association, Inc.

Interventional Cardiology

Intensifying Platelet Inhibition With Tirofiban in Poor Responders to Aspirin, Clopidogrel, or Both Agents Undergoing Elective Coronary Intervention

Results From the Double-Blind, Prospective, Randomized Tailoring Treatment With Tirofiban in Patients Showing Resistance to Aspirin and/or Resistance to Clopidogrel Study

Marco Valgimigli, MD, PhD, FESC; Gianluca Campo, MD; Nicoletta de Cesare, MD; Emanuele Meliga, MD; Pascal Vranckx, MD; Alessandro Furgieri, MD; Dominick J. Angiolillo, MD, PhD; Manel Sabatè, MD, PhD; Martial Hamon, MD; Alessandra Repetto, MD; Salvatore Colangelo, MD; Salvatore Brugaletta, MD; Giovanni Parrinello, PhD; Gianfranco Percoco, MD; Roberto Ferrari, MD, PhD, FESC, for the Tailoring Treatment With Tirofiban in Patients Showing Resistance to Aspirin and/or Resistance to Clopidogrel (3T/2R) Investigators

From the Department of Cardiology, University of Ferrara, Ferrara, Italy (M.V., G.C., R.F.); Cardiovascular Research Centre, Salvatore Maugeri Foundation, IRCCS, Gussago, BS, Italy (M.V., R.F.); Policlinico S. Marco, Zingonia, BG, Italy (N.d.C.); Cardiovascular Intervention Laboratory San Giovanni Bosco Hospital, Turin, Italy (E.M.); Virga Jesseziekenhuis, Hasselt, Belgium (P.V.); Department of Medical and Surgical Cardiology, Villa Maria, Cecilia Hospital, Cotignola, RA, Italy (A.F.); Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.); Interventional Cardiology Unit, Cardiology Department, Saint Paul University Hospital, Barcelona, Spain (M.S., S.B.); Department of Cardiology at the University Hospital of Caen, Normandy, France (M.H.); Istituto di Ricovero e Cura a Carattere Scientifico, Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy (A.R.); Unit of Cardiology, Azienda Ospedaliera S. Giovanni Battista, Turin, Italy (S.C.); Medical Statistics Unit, University of Brescia, Brescia, Italy (G. Parrinello); and Cardiology, Lagosanto Hospital, Lagosanto, Italy (G. Percoco).

Correspondence to Marco Valgimigli, MD, PhD, University of Ferrara, Cardiovascular Institute, S. Anna Hospital, Corso Giovecca 203, 44100 Ferrara, Italy. E-mail vlgmrc{at}unife.it

Received November 2, 2008; accepted April 30, 2009.

Background— Inhibition of platelet aggregation after aspirin or clopidogrel intake varies greatly among patients, and previous studies have suggested that poor response to oral antiplatelet agents may increase the risk of thrombotic events, especially after coronary angioplasty. Whether this reflects suboptimal platelet inhibition per se, which might benefit from more potent antiplatelet agents such as tirofiban, is unknown.

Methods and Results— We screened 1277 patients to enroll 93 aspirin, 147 clopidogrel, and 23 dual poor responders, based on a point-of-care assay, who underwent elective coronary angioplasty at 10 European sites for stable or low-risk unstable coronary artery disease. Patients were randomly assigned in a double-blind manner to receive either tirofiban (n=132) or placebo (n=131) on top of standard aspirin and clopidogrel therapy. The primary end point, consisting of troponin I/T elevation at least 3 times the upper limit of normal, was attained in 20.4% (n=27) in the tirofiban group compared with 35.1% (n=46) in the placebo group (relative risk, 0.58; 95% confidence interval, 0.39 to 0.88; P=0.009). The rate of major adverse cardiovascular events within 30 days in the tirofiban group also was reduced (3.8% versus 10.7%; P=0.031). The overall incidence of bleeding was low, likely explained by a substantial use of the transradial approach, and did not differ between the 2 groups.

Conclusions— In low-risk patients according to clinical presentation who had poor responsiveness to standard oral platelet inhibitors via a point-of-care assay, intensified platelet inhibition with tirofiban lowers the incidence of myocardial infarction after elective coronary intervention.

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Circulation 2009 119: 3163-3164. [Extract] [Full Text]