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Platelet Glycoprotein Iib/Iiia Integrin Blockade with Eptifibatide in Coronary Stent Intervention the ESPRIT Trial: a Randomized Controlled Trial

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Platelet Glycoprotein Iib/Iiia Integrin Blockade with Eptifibatide in Coronary Stent Intervention the ESPRIT Trial: a Randomized Controlled Trial ORIGINAL CONTRIBUTION Platelet Glycoprotein IIb/IIIa Integrin Blockade With Eptifibatide in Coronary Stent Intervention The ESPRIT Trial: A Randomized Controlled Trial J. Conor O’Shea, MD Context The Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Gail E. Hafley, MS Therapy (ESPRIT) trial showed the efficacy of adjunctive, double-bolus eptifibatide therapy Sally Greenberg, PhD in reducing ischemic complications of nonurgent coronary stent implantation at 48 hours and at 30 days. Vic Hasselblad, PhD Objective To determine whether the beneficial effects of eptifibatide persist at 6 months Todd J. Lorenz, MD after treatment. Michael M. Kitt, MD Design Follow-up study of a randomized, double-blind, placebo-controlled, crossover- permitted trial conducted from June 1999 through February 2000. John Strony, MD Setting Ninety-two tertiary care centers in the United States and Canada. James E. Tcheng, MD Participants A total of 2064 patients scheduled to undergo nonurgent percutane- for the ESPRIT Investigators ous coronary intervention with stent implantation. ORONARY THROMBOSIS IS CEN- Intervention Patients were randomly assigned to receive placebo or eptifibatide (two tral to the pathogenesis of ath- 180-µg/kg boluses 10 minutes apart and continuous infusion of 2.0 µg/kg per minute), started immediately before stent implantation and continued for 18 to 24 hours. Com- erosclerosis, acute myocar- plete follow-up data were available for 988 (95.0%) of 1040 patients given eptifi- dial infarction (AMI), acute batide and 977 (95.4%) of 1024 patients given placebo. Ccoronary syndromes, and ischemic com- Main Outcome Measures Composite rates of death or myocardial infarction (MI); plications of percutaneous coronary in- 1 death, MI, or target vessel revascularization; and their individual components 6 months tervention (PCI). Aside from the obvi- after enrollment, compared between the 2 groups. ous and dramatic effects of abrupt thrombosis of an epicardial vessel, the ef- Results By 6 months, the composite end point of death or MI had occurred in 7.5% of eptifibatide-treated patients and in 11.5% of placebo-treated patients (hazard ratio [HR], fects of thrombosis on microcirculation 0.63; 95% confidence interval [CI], 0.47-0.84; P=.002). The composite of death, MI, or (such as microembolization and vaso- target vessel revascularization was 14.2% in eptifibatide-treated patients vs 18.3% in pla- spasm) also portend poor outcomes in cebo-treated patients (HR, 0.75; 95% CI, 0.60-0.93; P=.008). Most of this benefit accrued coronary artery disease.2 Several large, early (,48 hours after initiation of therapy) and was maintained through 6 months. Six- randomized clinical trials have shown month mortality in the eptifibatide group was 0.8% vs 1.4% in the placebo group (HR, that inhibition of platelet aggregation 0.56; 95% CI, 0.24-1.34; P=.19) and target vessel revascularization occurred in 8.6% of with platelet glycoprotein (Gp) IIb/IIIa the eptifibatide group vs 9.4% of the placebo group (HR, 0.91; 95% CI, 0.68-1.22; P=.51). receptor antagonists improves out- Conclusion Adjunctive eptifibatide therapy during coronary stent implantation pro- comes in patients presenting with acute vides benefit through 6-month follow-up. coronary syndromes and after PCI.3,4 JAMA. 2001;285:2468-2473 www.jama.com These agents mitigate the thrombotic cas- cade both by blocking Gp IIb/IIIa, the pri- adverse cardiac events in several coro- tion, and unstable angina.14 In the En- mary surface-membrane receptor re- nary indications, including PCI,12 AMI hanced Suppression of the Platelet IIb/ sponsible for platelet aggregation, and by with13 or without14 ST-segment eleva- IIIa Receptor with Integrilin Therapy indirectly inhibiting the generation of thrombin.5-11 Author Affiliations: Duke Clinical Research Institute, Therapeutics, the trial sponsor. Dr Tcheng receives re- Durham, NC (Drs O’Shea, Hasselblad, and Tcheng and search grant support and speakers bureau honoraria Eptifibatide is an intravenous, rap- Ms Hafley); COR Therapeutics Inc, South San Francisco, and serves as a consultant for COR Therapeutics and idly reversible, competitive inhibitor of Calif (Drs Greenberg, Lorenz, and Kitt); and Schering- Schering-Plough Research Institute. Plough Research Institute, Kenilworth, NJ (Dr Strony). Corresponding Author: James E. Tcheng, MD, Duke Gp IIb/IIIa. Therapy with eptifibatide Financial Disclosures: Drs Greenberg, Lorenz, and Kitt Clinical Research Institute, PO Box 17969, Durham, has been shown to reduce short-term are employed by and own stock and options in COR NC 27705 (e-mail: [email protected]). 2468 JAMA, May 16, 2001—Vol 285, No. 19 (Reprinted) ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 EPTIFIBATIDE IN CORONARY STENTING (ESPRIT) trial, high-dose, double- ,1003103/µL), or a serum creatinine 200 to 300 seconds. Treatment with bolus eptifibatide was evaluated in non- level of more than 4.0 mg/dL (350 ticlopidine or clopidogrel was permit- urgent coronary stenting. This trial was µmol/L). ted on the day of the procedure but not terminated early for efficacy in Febru- beforehand; the choice of loading dose ary 2000.15 Final analysis of the pri- Treatments was decided by the treating physician. mary composite end point—death, MI, Patients were randomized in a 1:1 ratio The PCI was performed according to lo- need for urgent target vessel revascu- to receive either placebo or eptifibatide cal standards, and any approved stent larization, or crossover to Gp IIb/IIIa (Integrilin, COR Therapeutics, South San could be implanted. inhibitor therapy for thrombosis within Francisco, Calif, and Schering-Plough To provide emergency, open-label Gp 48 hours—showed a 37% relative risk Research Institute, Kenilworth, NJ), IIb/IIIa inhibitor therapy (for direct treat- reduction with treatment (10.5% with started immediately prior to PCI. The ment of abrupt closure, no reflow, coro- placebo vs 6.6% with eptifibatide; randomization allocation code was gen- nary thrombosis, or similar complica- P=.002). At 30 days, the key second- erated using random permuted blocks tions of PCI), “bailout” kits were ary composite end point of death, MI, within each investigative site. Each site supplied to the sites. These kits con- or urgent target vessel revasculariza- kept a randomization schedule unique tained 2 bolus vials of either eptifi- tion was reduced by a relative 35% to that site. Study drug kits were pre- batide (for patients allocated to the pla- (10.4% vs 6.8%; P=.003).15 The pur- pared only after the guiding scout im- cebo group) or placebo (for patients pose of the present analysis was to de- ages had been obtained in the catheter- allocated to the eptifibatide group). Once termine whether these benefits contin- ization laboratory in preparation for the bolus bailout treatment had begun, ued at 6 months for patients enrolled intervention. Patients were considered the study drug infusion was discontin- in the ESPRIT trial. randomized at the time of any adminis- ued and open-label eptifibatide infu- tration of study drug. If the clinician de- sion was initiated. Bailout use of Gp IIb/ METHODS cided not to give the study drug for any IIIa inhibition did not result in Patients reason, the patient was not randomized unblinding of treatment assignment. The design and methods of the ESPRIT and was not considered part of the study. The protocol was approved by the in- trial have been described.15,16 Briefly, 92 If a kit was prepared but not used, un- stitutional review board at each clini- centers in the United States and Canada blinding did not occur and replace- cal site, and patients gave informed con- enrolled patients who were scheduled ment kits were used to reestablish the sent for participation in the trial and to undergo nonurgent coronary stent- correct sequence in the randomization follow-up for 1 year. Masking of study ing. Enrollment of 2064 patients oc- list for the next eligible patient. Once drug allocation was maintained through curred from June 1999 through Febru- study drug was given, a patient’s partici- 1 year of follow-up. ary 2000. The primary inclusion pation in the study was communicated criterion was intent to treat a native coro- to the coordinating center within 30 min- Definitions nary artery with stent implantation with- utes of randomization. This strategy Outcomes at 6 months, including death, out planned use of a Gp IIb/IIIa inhibi- served to minimize the number of pa- MI, and target vessel revasculariza- tor. Exclusion criteria included MI tients randomized but not actually tion, were prospectively defined sec- within 24 hours before randomization treated in ESPRIT. ondary end points of the trial. Target and ongoing chest pain precipitating ur- Study drug kits were packaged to be vessel revascularization was defined as gent referral for PCI. Other exclusion cri- indistinguishable, regardless of con- coronary artery bypass grafting or a sec- teria included PCI within the previous tent. Any drug kit that became unus- ond PCI deemed by the site investiga- 90 days, previous stent implantation at able was replaced with another uniquely tor to involve the original target ves- the target location, staged PCI antici- numbered kit of the same treatment. sel. All other revascularizations were pated less than 30 days after random- This kit then was given to the next pa- reviewed by a clinical events commit- ization, treatment with a Gp IIb/IIIa in- tient enrolled at that site. Eptifibatide tee (CEC) to determine whether the hibitor or a thienopyridine within 30 was given as two 180-µg/kg boluses 10 procedure met the criteria for target ves- days before randomization, stroke or minutes apart and as a continuous in- sel revascularization. transient ischemic attack within 30 days fusion of 2.0 µg/kg per minute (1.0 An end-point MI could occur by 1 of before randomization, history of hem- µg/kg per minute in patients with a se- 2 criteria.
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