1. Efficacy and Safety of Glycoprotein IIb/IIIa Inhibitors During Elective Coronary Revascularization A meta-analysis of randomized trials performed in the era of stents and thienopyridines Winchester DE, Wen X, Brearley WD, Park KE, Anderson RD, Bavry AA

2. Disclosures All authors have no conflicts to disclose
This research was supported by an unrestricted grant from the Florida Heart Research Institute

3. Background and Context
Glycoprotein IIb/IIIa inhibitors (GPI)
Potent antiplatelet agents
Commonly used during percutaneous coronary intervention (PCI)
Contemporary PCI typically performed with:
Stents
Thienopyridines
Aim: To assess efficacy and safety of GPI in contemporary elective PCI
Hypothesis: Benefits of GPI will be minimal and bleeding risks will be elevated

4. Methods Meta-analysis of: MEDLINE, Cochrane, clinicaltrials.gov
Randomized controlled trials of GPI vs. control
DerSimonian-Laird model for risk ratios (RR)
STATA v11 (College Station, TX)
Independent data extraction by two authors (WDB and KEP)
Verification and resolution of disagreements by two authors (DEW and AAB)

5. Study Selection 6,377 studies identified by search strategy
MeSH terms and keywords
Limited to humans and clinical trials
648 studies remained
Abstracts hand searched and non-elective PCI studies were eliminated
22 studies included in meta-analysis

6. Outcomes Periprocedural Myocardial Infarction Major Bleeding
Minor Bleeding
All-cause mortality

7. Baseline Characteristics
Mean age = 63 years
Mean percent female = 25%
Median stent use = 98%
Thienopyridine given prior to PCI in 94% (given after PCI in remainder)

8. Periprocedural Infarction
5.1% with GPI versus 8.3% with control
RR=0.66 (95% CI 0.55 to 0.79), p<0.0001

9. Major Bleeding 1.2% with GPI versus 0.9% with control
RR=1.37 (95% CI 0.83 to 2.25), p=0.22

10. Minor Bleeding 3.0% with GPI versus 1.7% with control
RR=1.70 (95% CI 1.28 to 2.26), p<0.0001

11. Mortality 0.3% with GPI versus 0.5% with control
RR=0.70 (95% CI 0.36 to 1.33), p=0.27

12. Metaregression
Influence of various covariates on myocardial infarction
Percentage of patients with diabetes (p = 0.61)
Publication year (p = 0.99)
Thienopyridine before vs after PCI (p = 0.99)
Higher dose of heparin in control arm (p = 0.78)

13. Limitations Could not stratify patients by other known risk factors
Platelet reactivity, statin use, lesion complexity
Included ticlopidine studies
However, efficacy is considered similar to clopidogrel

14. Conclusions
Using GPI during modern elective PCI with thienopyridines and stenting has the following effects:
Postprocedural infarction is significantly reduced, ARR = 3.2%, risk ratio = 0.66
Major bleeding is not significantly increased
Minor bleeding is significantly increased, ARR = 1.3%, risk ratio = 1.70
No net effect on mortality
Winchester DE, et al JACC 2011