Background: In the EARLY ACS trial, eptifibatide 12 hours or more before angiography was not superior to the provisional use of eptifibatide in patients with non-ST-segment elevation myocardial infarction (NSTE MI). This sub-analysis examines the efficacy of early eptifibatide in patients with elevated troponin (Tn) on admission. Methods: In EARLY ACS, 9406 high-risk NSTE acute coronary syndrome patients expected to undergo an invasive strategy were randomized to early vs. delayed provisional eptifibatide. Of these, 7881 (84%) had an elevated Tn at baseline and were included in our analyses. We determined the median peak Tn level within 48 hours by treatment group using peak to upper limit of normal ratio and calculated area under the curve (AUC) for CK-MB at 48 hours using the trapezoidal rule method. We also determined the rates of the 30-day composite of death, MI, or recurrent ischemia requiring urgent revascularization (MACE) and in-hospital TIMI major bleeding (overall and non-CABG-related) by treatment group. Comparisons between groups were made using t-tests or Wilcoxon rank sum tests for continuous variables and chi-square or log-rank tests for event rates. Results: Median 48-hour Tn level and CK-MB AUC were significantly lower in the group receiving eptifibatide compared with the early placebo group (median 48-hour Tn 13.2 [3.4-53.1] vs. 16.2 [4.2-58.2], p=0.02; median CK-MB AUC 83.2 [46.1-191.8] vs. 89.4 [47.9-199.6], p=0.04, respectively). MACE was significantly lower in Tn-positive patients who received early eptifibatide (13.2% vs. 14.7%, p=0.04), but overall TIMI major bleeding was significantly higher (2.7% vs. 1.9%, p=0.02) compared with the early placebo group. Conclusion: Routine early eptifibatide in NSTE MI patients with an elevated Tn at baseline was associated with smaller infarct size at 48 hours and improved ischemic outcome, but at the cost of higher bleeding risk.
Rasoul, S., van't Hof, A., Clare, R., Atar, D., James, S., Tanguay, J.-F., … Newby, L. K. (2012). ROUTINE EARLY EPTIFIBATIDE, INFARCT SIZE, AND OUTCOMES IN NON-ST-SEGMENT ELEVATION ACUTE CORONARY SYNDROME PATIENTS WITH ELEVATED TROPONIN ON ADMISSION. Journal of the American College of Cardiology, 59(13), E498. https://doi.org/10.1016/s0735-1097(12)60499-9