Integrating GP IIb IIIa inhibitors in the management of acute coronary syndromes

Patients admitted with acute coronary syndromes (ACS), ranging from unstable angina to extensive myocardial infarction (MI), are at risk for mortality and (re)infarction. At the time of hospital admission patient groups can be identified with greater or lesser risk for subsequent events. Patients with persistent ST-segment elevation require immediate reperfusion therapy. In other patients with ACS, glycoprotein (GP) IIb/IIIa receptor blockers reduce the incidence of death, recurrent MI or recurrent ischaemia. This effect is particularly apparent in patients undergoing percutaneous coronary intervention (PCI), but also present in those continuing on medical therapy. Elevated plasma troponin levels reflect myocardial damage, caused by active thrombosis in patients with ACS. GP IIb/ IIIa receptor blockers have a major benefit in those patients with elevated troponin levels at presentation, while no benefit is apparent in those without elevated troponin values. The optimal time at which to undertake invasive therapy is debated. An analysis from PURSUIT (Platelet IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy) implies that the lowest rate of subsequent complications is achieved in patients undergoing PCI very early, within 24 h after enrolment, while receiving eptifibatide. In any case treatment with GP IIb/IIIa receptor blockers should be continued until coronary intervention is completed.