Outcomes with the use of glycoprotein IIb/IIIa inhibitors in non-ST-segment elevation acute coronary syndromes

Objective: To compare the characteristics, management, and outcomes of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) who would have been eligible for inclusion in clinical trials of glycoprotein (GP) IIb/IIIa inhibitors with those of ineligible patients.

Design: Multinational, prospective, observational study (GRACE, Global Registry of Acute Coronary Events).

Setting: Patients hospitalised for a suspected acute coronary syndrome and enrolled in GRACE between April 1999 and December 2004.

Patients: 29 039 patients with NSTE ACS.

Main outcome measures: Characteristics and outcomes were compared for trial-eligible (75.0%) and trial-ineligible (25.0%) patients.

Results: GP IIb/IIIa inhibitors were administered to 20.0% of eligible and 15.3% of ineligible patients. Compared with eligible patients, ineligible patients who received GP IIb/IIIa inhibitors had significantly higher rates of hospital death (6.8% vs 3.7%) and major bleeding (4.9% vs 2.2%). After adjustment for their higher baseline risk, ineligible patients still experienced higher hospital death rates (adjusted odds ratio (OR) 1.60; 95% confidence interval (CI) 1.01 to 2.39), but not higher bleeding rates, than the eligible group. Use of GP IIb/ IIIa inhibitors was associated with a trend towards lower 6-month mortality in eligible (OR 0.86, 95% CI 0.72 to 1.02) and ineligible (OR 0.82, 95% CI 0.65 to 1.05) patients compared with those in whom this therapy was not used.

Conclusions: GP IIb/IIIa inhibitors were markedly under-used in the real-world population, irrespective of whether patients were trial-eligible or not. Despite the higher risk of ineligible patients, the benefits of GP IIb/ IIIa inhibitors appear to be no less than in eligible patients.