Authors' objectives:

To provide guidance on the use of glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndromes. This guidance replaces Technology Appraisal Guidance No 12 issued in September 2000.

Authors' recommendations: Guidance: 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.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.nice.org.uk/cat.asp?c=36351

Year Published: 2002

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: England, United Kingdom

Organisation Name: National Institute for Clinical Excellence

Contact Address: MidCity Place, 71 High Holborn, London WC1V 6NA, UK. Tel: +44 020 7067 5800; Fax: +44 020 7067 5801

Contact Name: nice@nice.nhs.uk

Contact Email: nice@nice.nhs.uk

Copyright: National Institute for Clinical Excellence (NICE)