Outcomes Do Not Suffer With Shortened Eptifibatide Infusion During PCI

Providing a shorter infusion of the glycoprotein IIb/IIIa inhibitor (GPI) eptifibatide to patients undergoing PCI cuts costs and does not worsen outcomes, according to a single-center study published online January 5, 2015, ahead of print in the American Journal of Cardiology.Take Home: Outcomes Do Not Suffer With Shortened Eptifibatide Infusion During PCI

In a retrospective review of electronic medical records, Scott D. Nei, PharmD, of the Mayo Clinic (Rochester, MN), and colleagues evaluated the impact of a practice change that reduced the duration of infusions of eptifibatide (Integrilin; Merck) from 18 hours to the time needed to infuse a single 75-mg vial started during PCI (given at maximum rate of 15 mg hour). The study included 1,647 patients who underwent PCI before the change and 1,237 who were treated after the change. Median infusion times for the 2 groups were 18.1 and 6.6 hours, respectively.

Baseline characteristics were generally similar between those treated before and after the change, although patients who received standard 18-hour infusions had higher pre-PCI platelet counts, were less likely to undergo radial catheterization or to have NSTEMI, and were more likely to undergo elective procedures. The proportion of STEMI patients remained consistent throughout the study period.

Infusion length was not related to the occurrence of composite cardiovascular events (all-cause death, STEMI, CABG, or ischemic stroke), the individual components, TVR, or major or minor bleeding during the index hospitalization (table 1).

  In-Hospital Outcomes

Shortening infusions did, however, result in the use of 1.6 fewer vials of eptifibatide for an average savings of $823 per patient.

Optimal Infusion Length Unclear

The eptifibatide infusion length of 18 to 24 hours was established by the ESPRIT trial more than a decade ago, but that was before loading with oral dual antiplatelet therapy (DAPT) became standard practice. Since then, questions have been raised about whether such a long infusion is necessary.

The BRIEF-PCI trial, for example, showed that the infusion could be shortened to less than 2 hours for uncomplicated, nonemergent PCI without negatively affecting ischemic events. And another study in NSTE-ACS patients showed that giving a GPI bolus without infusion (mostly using eptifibatide) reduces bleeding and costs without increasing ischemic complications.

The current analysis, although single-center and retrospective, adds to the evidence supporting shorter infusions as “the first study to evaluate in-hospital clinical outcomes of a shortened-duration eptifibatide infusion administered to a cohort that included high-risk, emergent PCI patients,” according to the authors.

Overall Shift Seen Toward Shorter Infusion

Dr. Nei told TCTMD in an email that he and his colleagues were surprised that bleeding was not reduced with the shorter infusion but highlighted the lower costs. He noted that the use of an abbreviated infusion seems to be a trend across centers, at least in the Midwest.

Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), said he, too, was “a little bit” surprised about the lack of a difference in bleeding, adding that a more systematic look at bleeding might have revealed a gap between the groups.

He told TCTMD in a telephone interview that the before-and-after design of the study was a strength, although its lack of multivariate adjustment prevented making firm conclusions.

Nevertheless, the general trend across centers is to move toward shorter infusions, he said, stemming from bleeding concerns, the discharge of many patients on the same day PCI is performed, and the use of newer stent techniques and more potent antiplatelets, which potentially lessen thrombotic risk.

“More and more hospitals and doctors are adopting shorter duration infusions, and although underpowered, this study and others like it do suggest that it may be an acceptable approach for patients undergoing PCI,” Dr. Kirtane said.

The authors conclude that “a prospective randomized trial would be necessary to confirm the observations suggested by this study.”

 


Source:
Nei SD, Armon JJ, Dierkhising RA, et al. Effect of a shortened duration eptifibatide infusion (75 mg) as adjunctive therapy for percutaneous coronary intervention on in-hospital cardiovascular outcomes and bleeding. Am J Cardiol. 2015;Epub ahead of print.

 

Related Stories:

Todd Neale is the Associate News Editor for TCTMD and a Senior Medical Journalist. He got his start in journalism at …

Read Full Bio
Disclosures
  • Dr. Nei reports no relevant conflicts of interest.
  • Dr. Kirtane reports institutional research grants from Abbott Vascular, Abiomed, Boston Scientific, Eli Lilly, Medtronic, St. Jude Medical, and Vascular Dynamics.

Comments