Abstract 3219: Comparison of Upstream Tirofiban and Eptifibatide Use in Patients with Moderate and High Risk Acute Coronary Syndromes: an ACUITY Substudy
Background. Both tirofiban (TR) and eptifibatide (EP) reduce ischemic complications compared to heparin alone when initiated “upstream” prior to angiography in pts with acute coronary syndromes (ACS). Whether one agent is safer and/or more effective has not been examined.
Methods. Outcomes from the prospective multicenter ACUITY trial were examined in 4323 pts with moderate and high risk ACS who were randomized to and received heparin (unfractionated or enoxaparin) or bivalirudin plus routine upstream initiation of GPIIb/IIIa inhibitors. The protocol permitted operator selection of either TR (n=1493) or EP (n=2830). Multivariable and propensity-based adjustment were used to assess the independent association of TR or EP treatment upon pre-specified study endpoints at 30 days.
Results. TR pts were more frequently enrolled outside of North America, while EP patients were more frequently enrolled in North America. TR pts were older, but had fewer baseline cardiac risk factors and prior revascularization procedures. Baseline cardiac biomarker elevation (68.5% vs. 53.4%) and ST-segment deviation (45.8% vs. 29.1%) were more prevalent among TR pts (p<0.001 for both). In unadjusted analyses, treatment with TR compared to EP was associated with a trend towards less composite ischemia (death/MI/unplanned revascularization: 6.1% vs. 7.6%, p=0.06), similar rates of non-CABG major bleeding (5.8% vs. 6.5%, p=0.39), and a trend toward reduced net clinical outcomes (10.6% vs. 12.6%, p=0.06). After multivariable and propensity-based adjustment including enrollment geography as a covariate, TR and EP were associated with non-significantly different odds for the primary 30-day safety and efficacy outcome endpoints (Table⇓).
Conclusions. Among moderate and high risk pts with ACS treated with upstream GPIIb/IIIa inhibitors, the non randomized use of TR and EP did not result in significantly different rates of adverse ischemic events or major bleeding.