Platelet XXXX -IIIa Receptor Antagonists in Primary Angioplasty: Back to the Future.

@entity1 @entity455 @entity583 @entity548 @entity1188 @entity1427 @entity453 @entity715
@entity453 and @entity583 still represent the leading cause of mortality in developed countries. Therefore, great efforts have been made in the last decades to improve reperfusion strategies and adjunctive antithrombotic therapies. In fact, despite optimal epicardial recanalisation, a large proportion of @entity1 still experience impaired reperfusion and in-stent @entity715 . The adjunctive use of glycoprotein (GP) IIb-IIIa inhibitors may certainly contribute in the @entity455 , especially when administered in the early phase of @entity1188 . In fact, in this phase a larger platelet composition of the @entity715 and the presence of a larger amount of viable myocardium, as compared to a delayed phase, may increase the benefits from this therapy and counterbalance the potential higher risk of @entity548 . A large body of evidence has been accumulated on the benefits from @entity1427 -IIIa inhibitors in terms of prevention of stent @entity715 , and benefits in mortality, especially among high-risk @entity1 and as upstream strategy. Therefore, based on current available data, @entity1427 -IIIa inhibitors can be recommended as early as possible (upstream strategy) among high-risk @entity1 , such as those with advanced Killip class or anterior @entity583 ( @entity583 ), and those presenting within the first three hours. Even though it is not universally accepted, in our opinion this strategy should be implemented in a pre-hospital setting (in ambulance) or at first hospital admission (Emergency Room or Coronary Care Unit, irrespective of whether they are in the spoke or hub hospitals). Peri-procedural intracoronary administration of @entity1427 -IIIa inhibitors has not provided additional benefits as compared to intravenous administration and therefore cannot be recommended. Even though the vast majority of trials have been conducted with abciximab, several meta-analyses comparing small molecules (mainly high-dose tirofiban rather than eptifibatide) versus abciximab showed similar angiographic and clinical results between the molecules. Several recent investigations and meta-analyses have documented the higher risk of stent @entity715 associated with bivalirudin as compared to unfractionated heparin (UFH). Being that these results are independent from the use of @entity1427 -IIIa inhibitors, UFH should still remain the anticoagulation therapy of choice in @entity583 ( @entity583 ) @entity1 . Minimisation of @entity548 complications by extensive use of the radial approach, in the setting of @entity583 , may further contribute to the adoption of a more aggressive antithrombotic and antiplatelet therapy incorporating the use of @entity1427 -IIIa inhibitors. The establishment of dedicated networks for @entity583 , and the large @entity583 campaign, will certainly contribute to increase the proportion of @entity1 presenting at first medical contact within the early phase (3  h) of @entity1188 and therefore highly suitable for a more aggressive pharmacoinvasive approach with upstream administration of @entity1427 -IIIa inhibitors. In fact, although the current therapeutic targets of increased rates of timely reperfusion, mainly by primary percutaneous coronary intervention (PCI), has been achieved, a deep look into the future in the fight against @entity583 will certainly put aborting @entity1188 as the major desirable target to be achieved.
