Platelet glycoprotein inhibitors in patients with medically managed acute coronary syndrome: Does the enthusiasm exceed the science?

作     者：Schriger, DL Herbert, ME 

作者机构：Univ Calif Los Angeles Sch Med Ctr Emergency Med Los Angeles CA 90024 USA Univ Calif Los Angeles Sch Nursing Los Angeles CA 90024 USA Olive View UCLA Med Ctr Dept Emergency Med Los Angeles CA USA 

出 版 物：《ANNALS OF EMERGENCY MEDICINE》 (急救医学纪事)

年 卷 期：2001年第38卷第3期

页      面：249-255页

核心收录：

学科分类：1002[医学-临床医学] 10[医学] 

主　　题：心绞痛 不稳定型/药物疗法 心绞痛 不稳定型/经济学 心绞痛 不稳定型/死亡率 费用效益分析 循证医学 心肌梗死/药物疗法 心肌梗死/经济学 心肌梗死/死亡率 血小板聚集抑制剂/经济学 血小板聚集抑制剂/治疗应用 血小板糖蛋白GPⅡb-Ⅲa复合物/拮抗剂和抑制剂 危险性评估 存活率 人类 

摘      要：Guidelines from the American Heart Association and the American College of Cardiology, as well as numerous review articles, have strongly and enthusiastically recommended that platelet glycoprotein IIb/IIIa inhibitors be used in patients with medically managed unstable angina or non-ST-segment myocardial infarction (UA/NSTEMI). We explore whether there is sufficient experimental evidence to justify these recommendations. We review the 4 large randomized trials of US Food and Drug Administration-approved platelet glycoprotein IIb/IIIa inhibitors that included medically managed UA/NSTEMI patients, first taking each trial s results at face value and then in the context of likely biases. The risk differences, unadjusted for potential biases, are 2.5% (0.6%, 4.4%) for the Platelet Receptor Inhibition in Ischemic Syndrome Management (PRISM) study, 2.3% (-1.9%, 6.5%) for the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) study (tirofiban plus heparin), 0.9% (-0.9%, 2.8%) for the Platelet Glycoprotein IIb/IIIa in Unstable Angina Receptor Suppression Using Integrilin Therapy (PURSUIT) trial, -0.2% (-1.7%, 1.3%) for the least harmful treatment arm of the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-IV) trial, and -1.9% (-6.8%, 3.0%) for the PRISM-PLUS study (tirofiban alone) (positive numbers indicate benefit). The 95% confidence interval produced by combining the studies using a random effects model is -1.3% to 3.2% (mean 0.9%);this is consistent with drugs providing a small benefit, no benefit, or causing harm. Confounding caused by the nonrandom selection of patients for percutaneous transluminal coronary angioplasty and coronary artery bypass grafting in all trials except GUSTO-IV and problems arising from the fact that enrolled patients were much sicker than typical UA/NSTEMI patients are likely to have biased the studies away from t