The use of GP IIb/IIIa inhibitors into new perspectives: pre-catheterization laboratory administration

There is a general consensus that primary percutaneous coronary intervention (PCI) is the most adequate approach to reperfusion therapy in ST-elevation acute myocardial infarction (STEMI), associated with more efficient reperfusion and less mortality, recurrent ischaemia, stroke, and major bleeding complications compared with fibrinolysis. The systematic use of intravenous GP IIb/IIIa inhibitors, especially abciximab as an adjunctive therapy to primary PCI, is associated with a further reduction of mortality and ischaemic events in this setting. Nevertheless, the need for transfer from centres without round-the-clock PCI facility, may delay myocardial reperfusion and reduce the benefit of primary PCI. In order to accelerate the flow restoration in the infarct-related artery, during the gap between presentation and primary PCI, several pharmacological approaches have been proposed. The facilitation of primary PCI by full or half-dose fibrinolytics alone or in association with GP IIb/IIIa inhibitors has raised some unresolved safety and efficacy issues. Recent trials of the early administration of GP IIb/IIIa inhibitors prior to primary PCI have shown improved flow restoration and myocardial perfusion compared with in-catheterization laboratory administration of such treatments. Although such trials have been underpowered to detect differences regarding clinical outcomes among patient groups, the administration of intravenous abciximab is recommended as soon as possible in STEMI patients who are candidates to direct primary PCI. Further, large trials are needed to assess the efficacy, safety, and cost-effectiveness of facilitation strategies and to eventually identify subgroups of patients in whom such strategies would be most beneficial.