Acute coronary syndromes - glycoprotein IIb/IIIa inhibitors (review)

1. Guidance

This document replaces previous guidance on the use of glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndromes: NICE Technology Appraisal Guidance No. 12. London: National Institute for Clinical Excellence.

1.1. Glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors should be considered part of the management pathway for unstable angina or non-ST-segment-elevation myocardial infarction (NSTEMI). This management pathway also includes other pharmacological interventions and, where appropriate, early coronary angiography with a view to revascularisation either by percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG).

1.2. The intravenous use of a small-molecule glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitor (eptifibatide or tirofiban), in addition to aspirin and unfractionated heparin, is recommended as part of the initial medical management of patients with unstable angina or NSTEMI who are at high risk of subsequent myocardial infarction (MI) or death.

1.3. Whilst it is recognised that early angiography is desirable for high-risk patients, in situations where PCI does not occur or is not immediately available, initial medical management with GP IIb/IIIa inhibitors is still recommended.

1.4. It is recommended that in determining who is at high risk, clinicians should take into account combinations of risk factors such as: clinical history, including age, previous MI, and previous PCI or CABG; clinical signs, including continuing pain despite initial treatment; and clinical investigations, such as ECG changes (particularly dynamic or unstable patterns indicating myocardial ischaemia), haemodynamic changes and raised cardiac troponin levels (see 1.5).

1.5. Cardiac troponin testing is useful for diagnosing acute coronary syndromes and in risk stratification. However, it is recommended that in patients considered to be at high risk, treatment with a small-molecule GP IIb/IIIa inhibitor is initiated as soon as high-risk status is determined even though this may be before the result of a troponin test is known.

1.6. If PCI is indicated as part of the early management of unstable angina or NSTEMI, but it is delayed beyond the initial medical management phase, then the use of a GP IIb/IIIa inhibitor is recommended as an adjunct to the PCI. (Currently only abciximab is licensed as an adjunct to PCI.)

1.7. It is recommended that a GP IIb/IIIa inhibitor is considered as an adjunct to PCI for all patients with diabetes undergoing elective PCI, and for those patients undergoing complex procedures (for example, multi-vessel PCI, insertion of multiple stents, vein graft PCI or PCI for bifurcation lesions); currently only abciximab is licensed as an adjunct to PCI. In procedurally uncomplicated, elective PCI, where the risk of adverse sequelae is low, use of a GP IIb/IIIa inhibitor is not recommended unless unexpected immediate complications occur.

1.8. GP IIb/IIIa inhibitors are not currently licensed in the UK for use as an adjunct to thrombolytic therapy in ST-segment-elevation MI.