Treatment with tirofiban for acute coronary syndrome (ACS): a systematic review and network analysis

Efficacy and safety of tirofiban in patients with acute ischemic stroke treated with endovascular thrombectomy: A frequentist and Bayesian meta-analysis

BACKGROUND

Tirofiban is an antiplatelet treatment approved for acute coronary syndrome, but it has not been rigorously evaluated for efficacy and safety in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT).

METHODS

Electronic databases were systematically searched for studies conducted from January 1, 2015, to July 31, 2021, that evaluated tirofiban administration for patients with AIS treated with EVT in comparison with control. Risk ratios (RRs) and confidence intervals (CIs) were estimated for favorable functional outcomes (FFOs), mortality, and symptomatic intracranial hemorrhage (SICH), each 90 days after AIS. Bayesian hierarchical modeling was performed to obtain posterior RR and its 95% highest posterior density (HPD) for validation.

RESULTS

Compared with controls, tirofiban users exhibited increased FFOs (RR, 1.18; 95% CI, 1.08-1.30), decreased mortality (RR, 0.77; 95% CI, 0.64-0.92), and no difference in SICH (RR, 0.97; 95% CI, 0.77-1.23). Tirofiban users in the postbolus infusion subgroup exhibited increased FFOs (RR, 1.20; 95% CI, 1.07-1.35), decreased mortality (RR, 0.71; 95% CI, 0.58-0.88), and no increase in SICH (RR, 0.97; 95% CI, 0.72-1.29). The bolus-only subgroup showed no differences in FFO, mortality, or SICH between the tirofiban and control groups. Consistent results were obtained for posterior density of FFO (posterior RR, 1.20; 95% HPD, 1.06-1.34), mortality (posterior RR, 0.77; 95% HPD, 0.63-0.92), and SICH (posterior RR, 0.98; 95% HPD, 0.71-1.26).

CONCLUSION

For patients with AIS treated with EVT, tirofiban improved FFOs, decreased mortality, and did not increase SICH compared with controls; postbolus infusion for administering tirofiban was more favored than the bolus-only regimen.

Snake venom disintegrins update: insights about new findings

Snake venom disintegrins are low molecular weight, non-enzymatic proteins rich in cysteine, present in the venom of snakes from the families Viperidae, Crotalidae, Atractaspididae, Elapidae, and Colubridae. This family of proteins originated in venom through the proteolytic processing of metalloproteinases (SVMPs), which, in turn, evolved from a gene encoding an A Disintegrin And Metalloprotease (ADAM) molecule. Disintegrins have a recognition motif for integrins in their structure, allowing interaction with these transmembrane adhesion receptors and preventing their binding to proteins in the extracellular matrix and other cells. This interaction gives disintegrins their wide range of biological functions, including inhibition of platelet aggregation and antitumor activity. As a result, many studies have been conducted in an attempt to use these natural compounds as a basis for developing therapies for the treatment of various diseases. Furthermore, the FDA has approved Tirofiban and Eptifibatide as antiplatelet compounds, and they are synthesized from the structure of echistatin and barbourin, respectively. In this review, we discuss some of the main functional and structural characteristics of this class of proteins and their potential for therapeutic use.

Efficacy, Safety, and Role of Antiplatelet Drugs in the Management of Acute Coronary Syndrome: A Comprehensive Review of Literature

Acute coronary syndrome (ACS) is a complex condition characterized by myocardial ischemia or infarction which can lead to significant morbidity and death. Antiplatelet drugs play a crucial role in the management of ACS and have been shown to minimize the incidence of significant adverse cardiovascular events and recurrent myocardial infarction (MI). This comprehensive literature review is intended to summarize current information on the effectiveness, safety, and function of frequently used antiplatelet medications in treating ACS. Aspirin, clopidogrel, prasugrel, ticagrelor, abciximab, tirofiban, dipyridamole, cilostazol, and novel antiplatelets are included in the review. Aspirin's effectiveness as a first-line antiplatelet medication in ACS is well established. It has significantly lowered the risk of serious adverse cardiovascular events. Clopidogrel, prasugrel, and ticagrelor are P2Y12 receptor inhibitors found to lower the incidence of recurrent ischemia episodes in ACS patients. Using glycoprotein IIb/IIIa inhibitors such as abciximab, tirofiban, and eptifibatide is effective in managing ACS, especially in high-risk patients. Dipyridamole effectively reduces the risk of recurrent ischemic events in patients with ACS, particularly when used with aspirin. Cilostazol, a phosphodiesterase III inhibitor, has also been shown to reduce the risk of major adverse cardiovascular events (MACE) in patients with ACS. Antiplatelet drugs' safety in managing ACS has also been well established. Aspirin is generally well-tolerated with a low risk of adverse effects, although the risk of bleeding events, particularly gastrointestinal bleeding, cannot be eliminated. The P2Y12 receptor inhibitors have been associated with a small increase in the risk of bleeding events, particularly in patients with a high risk of bleeding. The glycoprotein IIb/IIIa inhibitors are associated with a higher risk of bleeding than other antiplatelet drugs, especially in high-risk patients. To summarize, antiplatelet drugs play a crucial role in the management of ACS, and the efficacy and safety of these drugs have been well-established in the literature. The choice of antiplatelet drugs will depend on the patient's risk factors, including age, comorbidities, and bleeding risk. The novel antiplatelets may offer new therapeutic options for managing ACS, and further studies are needed to determine their role in managing this complex condition.

The chemistry of snake venom and its medicinal potential

The fascination and fear of snakes dates back to time immemorial, with the first scientific treatise on snakebite envenoming, the Brooklyn Medical Papyrus, dating from ancient Egypt. Owing to their lethality, snakes have often been associated with images of perfidy, treachery and death. However, snakes did not always have such negative connotations. The curative capacity of venom has been known since antiquity, also making the snake a symbol of pharmacy and medicine. Today, there is renewed interest in pursuing snake-venom-based therapies. This Review focuses on the chemistry of snake venom and the potential for venom to be exploited for medicinal purposes in the development of drugs. The mixture of toxins that constitute snake venom is examined, focusing on the molecular structure, chemical reactivity and target recognition of the most bioactive toxins, from which bioactive drugs might be developed. The design and working mechanisms of snake-venom-derived drugs are illustrated, and the strategies by which toxins are transformed into therapeutics are analysed. Finally, the challenges in realizing the immense curative potential of snake venom are discussed, and chemical strategies by which a plethora of new drugs could be derived from snake venom are proposed.

Assessing the Efficacy and Safety of Tirofiban in Combination With Dual-antiplatelet Therapy in Progressive Ischemic Stroke Patients

ABSTRACT

This study assessed the efficacy and safety of tirofiban in combination with dual-antiplatelet therapy (DAPT) in progressive ischemic stroke. One hundred and four patients equally divided into a tirofiban group or DAPT group were enrolled from June 2018 to December 2019. Efficacy outcomes included National Institutes of Health Stroke Scale score for 14 days, and modified Rankin scale (mRs) scores as excellent (mRs 0-1) or favorable (mRs 0-2) measured 90 days after stroke. At 14 days, the tirofiban group had a lower National Institutes of Health Stroke Scale score compared with the DAPT group (F = 14.959, P = 0.000). The mRS scores of the 2 groups at 90 days after treatment were significantly different from those before treatment. At 90 days, excellent favorable functional outcome (mRS ≤ 2) was achieved in 33 of 52 (63.43%) patients in the tirofiban group compared with 25 of 52 (48.08%) patients in the DAPT group. The incidence of bleeding was 5.77% in the tirofiban group, compared with 0% in DAPT group. Intravenous (IV) tirofiban alone or combined with DAPT was shown to be safe and effectively improved clinical outcome in progressive ischemic stroke patients. IV tirofiban was shown to be superior to the DAPT regimen.

From Animal Poisons and Venoms to Medicines: Achievements, Challenges and Perspectives in Drug Discovery

Animal poisons and venoms are comprised of different classes of molecules displaying wide-ranging pharmacological activities. This review aims to provide an in-depth view of toxin-based compounds from terrestrial and marine organisms used as diagnostic tools, experimental molecules to validate postulated therapeutic targets, drug libraries, prototypes for the design of drugs, cosmeceuticals, and therapeutic agents. However, making these molecules applicable requires extensive preclinical trials, with some applications also demanding clinical trials, in order to validate their molecular target, mechanism of action, effective dose, potential adverse effects, as well as other fundamental parameters. Here we go through the pitfalls for a toxin-based potential therapeutic drug to become eligible for clinical trials and marketing. The manuscript also presents an overview of the current picture for several molecules from different animal venoms and poisons (such as those from amphibians, cone snails, hymenopterans, scorpions, sea anemones, snakes, spiders, tetraodontiformes, bats, and shrews) that have been used in clinical trials. Advances and perspectives on the therapeutic potential of molecules from other underexploited animals, such as caterpillars and ticks, are also reported. The challenges faced during the lengthy and costly preclinical and clinical studies and how to overcome these hindrances are also discussed for that drug candidates going to the bedside. It covers most of the drugs developed using toxins, the molecules that have failed and those that are currently in clinical trials. The article presents a detailed overview of toxins that have been used as therapeutic agents, including their discovery, formulation, dosage, indications, main adverse effects, and pregnancy and breastfeeding prescription warnings. Toxins in diagnosis, as well as cosmeceuticals and atypical therapies (bee venom and leech therapies) are also reported. The level of cumulative and detailed information provided in this review may help pharmacists, physicians, biotechnologists, pharmacologists, and scientists interested in toxinology, drug discovery, and development of toxin-based products.

Tirofiban combined with urokinase selective intra-arterial thrombolysis for the treatment of middle cerebral artery occlusion

The aims of the present study were to establish a model of embolic stroke in rabbits and to evaluate the efficacy and safety of intra-arterially administered tirofiban combined with urokinase thrombolysis. The middle cerebral artery occlusion model (MCAO) of embolic stroke was established in New Zealand rabbits via an autologous clot. The model rabbits were allocated at random into four groups: Tirofiban group (T group), urokinase group (UK group), tirofiban and urokinase group (T + UK group) and the control group (C group). The recanalization rate, relative-apparent diffusion coefficient (rADC) and neurological function deficit score (NFDS) values were compared among the four groups. The recanalization rate, rADC and NFDS values were improved in the T + UK group compared with the other groups. In summary, the intra-arterial administration of tirofiban combined with urokinase thrombolysis was a more effective intervention in an MCAO model compared with intra-arterial urokinase alone, and may promote reperfusion and reduce infarct volume.

Influence of Tirofiban maintenance duration on patients with acute myocardial infarction treated by percutaneous coronary intervention

OBJECTIVE

To evaluate the efficacy and short term prognosis of Tirofiban in different treatment duration in patients with acute ST segment elevation myocardial infarction (STEMI) and percutaneous coronary intervention (PCI) combined with intracoronary injection.

METHODS

A total of 125 patients with acute STEMI were enrolled in this study. They were randomly divided into two groups: control group (n = 61) and Tirofiban group (n = 64). The Tirofiban was used by intracoronary and intravenous administration in Tirofiban group which was randomly divided into three sub-groups according to the duration of Tirofiban by persistent intravenous injection for 12 hours, 24 hours or 36 hours. Thrombolysis in myocardial infarction flow and myocardial perfusion grades were recorded immediately after PCI. The adverse cardiac events and cardiac death within 180 days of PCI, and the adverse effects (hemorrhage and thrombocytopenia) were compared between the two groups and within Tirofiban sub-groups.

RESULTS

Grade 3 in myocardial perfusion was significantly better in Tirofiban group than control group (85.94% vs. 72.13%, P = 0.03) after PCI. There was one cardiac death in control group in 180 days after PCI. The adverse cardiac event rates between two groups was significant difference (16 patients in control group and only 8 in Tirofiban group, P = 0.047). There was no significant difference in incidence of hemorrhage complications and platelet counts between two groups. Nevertheless, hemorrhage complications in the 12- and 24-hour subgroups were less than 36-hour subgroup (P = 0.01).

CONCLUSIONS

Intravenous Tirofiban treatment reduced the adverse cardiac events and improved short term prognosis without increasing the adverse reactions of the drugs in patients undergoing PCI. The less rate of hemorrhage complication can be achieved in short-duration of Tirofiban by intravenous injection after PCI.

Efficacy and Safety of Intracoronary versus Intravenous Administration of Tirofiban during Percutaneous Coronary Intervention for Acute Coronary Syndrome: A Meta-Analysis of Randomized Controlled Trials

Background

Percutaneous coronary intervention (PCI) is known as the most effective treatment for acute coronary syndrome (ACS). However, without proper therapy and patient management, stent thrombosis after PCI may lead to another myocardial infarction. In addition to aspirin and clopidogrel, tirofiban is often used as an antiplatelet therapy in patients with ACS. To date, there has been no comprehensive evaluation of the efficacy and safety of intracoronary (IC) tirofiban administration for ACS patients undergoing PCI compared with intravenous (IV) administration. Therefore, this meta-analysis was conducted to investigate the clinical efficiency and safety of IC versus intravenous (IV) tirofiban in ACS patients undergoing PCI.

Methods

We searched PubMed and Medline for randomized controlled trials (RCTs) comparing IC versus IV administration of tirofiban in ACS patients undergoing PCI. We evaluated the effects of tirofiban on thrombolysis in myocardial infarction (TIMI) grade 3 flow after PCI, TIMI myocardial perfusion grade 3 (TMP grade 3), left ventricular ejection fraction (LVEF), major adverse cardiovascular events (MACE), target vessel revascularization (TVR), death, reinfarction and adverse drug effects (specifically bleeding events).

Results

Seven trials involving 1,027 patients were included in this meta-analysis. IC administration of tirofiban significantly increased TIMI grade 3 flow (OR 2.11; 95% CI 1.02 to 4.37; P = 0.04) and TMP grade 3 (OR 2.67; 95% CI 1.09 to 6.49; P = 0.03, I² = 64%) while reducing MACE (OR 0.46, 95% CI: 0.28 to 0.75; P = 0.002) compared with IV administration of tirofiban. No significant differences were observed in the occurrence of TVR, death, reinfarction and the incidence of bleeding events between the two groups.

Conclusions

This meta-analysis supports the use of IC over IV administration of tirofiban in patients with ACS to improve TIMI flow, TMP flow and MACE. However, there was no statistically significant difference in the risk of bleeding complications between the two groups.

Current state and novel approaches of antiplatelet therapy

An unresolved problem with clinical use of antiplatelet therapy is that a significant number of individuals either still get thrombosis or run the risk of life-threatening bleeding. Antiplatelet drugs are widely used clinically, either chronically for people at risk of athero/thrombotic disease or to prevent thrombus formation during surgery. However, a subpopulation may be resistant to standard doses, while the platelet targets of these drugs are also critical for the normal hemostatic function of platelets. In this review, we will briefly examine current antiplatelet therapy and existing targets while focusing on new potential approaches for antiplatelet therapy and improved monitoring of effects on platelet reactivity in individuals, ultimately to improve antithrombosis with minimal bleeding. Primary platelet adhesion-signaling receptors, glycoprotein (GP)Ib-IX-V and GPVI, that bind von Willebrand factor/collagen and other prothrombotic factors are not targeted by drugs in clinical use, but they are of particular interest because of their key role in thrombus formation at pathological shear.

A novel class of ion displacement ligands as antagonists of the αIIbβ3 receptor that limit conformational reorganization of the receptor

A collection of αIIbβ3 integrin receptor antagonists possessing a unique MIDAS metal ion displacement mechanism of action is presented. Insight into these agents' structure-activity relationships, binding modality, and pharmacokinetic and pharmacodynamic profiles highlight the potential of these small molecule ion displacement ligands as attractive candidates for clinical development.

Effects of Upstream Administration of Tirofiban Before Percutaneous Coronary Intervention on Spontaneous Reperfusion and Clinical Outcomes in Acute ST-Segment Elevation Myocardial Infarction

We assessed the effects of upstream administration of the glycoprotein IIb/IIIa inhibitor tirofiban before percutaneous coronary intervention (PCI) on spontaneous reperfusion (SR) of infarct-related artery (IRA) and the clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The incidence of SR of the IRA was significantly higher in the tirofiban group than in the no-tirofiban group (141 [36.5%] vs 21 [17.2%], P < .001). By multivariate logistic regression analysis, use of tirofiban (odds ratio 2.32, 95% confidence interval 1.25-4.31, P = .008) independently predicted the occurrence of SR. Kaplan-Meier survival analysis demonstrated that major adverse cardiovascular event-free survival was significantly higher in patients treated with tirofiban than in patients without tirofiban at 30-day (log rank = 11.65, P = .001) and 90-day follow-up (log rank = 16.79, P < .001). Upstream administration of tirofiban is significantly associated with increased SR of the IRA and favorable clinical prognosis in patients undergoing PCI for STEMI.

Effects of tirofiban maintenance duration on myocardial perfusion defect severity in anterior myocardial infarction

INTRODUCTION

Percutaneous coronary intervention (PCI) does not often produce optimal results, despite restoration of coronary blood flow at myocardial recovery, because of impaired microvascular perfusion. This study aimed to investigate and evaluate with (99m)Tc-sestamibi scan whether the results of PCI can be changed by maintenance infusion of tirofiban for 24 or 48 h in patients presenting with anterior ST-elevation myocardial infarction (STEMI).

METHODS

The study included 84 patients with anterior STEMI who were candidates for primary PCI and whose occlusion was in the proximal or mid-left anterior descending artery. Patients were given 25 μg/kg/3 min tirofiban and randomized to receive maintenance infusion at 0.15 μg/kg/min for 24 or 48 h. A resting (99m)Tc sestamibi scan was performed on the 5th day post-procedure before discharge. The primary efficacy endpoint was a patient's score on a 5-point scoring system for perfusion defect severity. Major adverse cardiac events (MACE) were defined as death from any cause, re-infarction, and clinically driven target-vessel revascularization within the first 6 months.

RESULTS

Baseline characteristics of the patients were similar in the two infusion groups (n = 42 per group). There was no significant difference in the symptom onset-to-presentation time or door-to-balloon time between the two groups. With the exception of basal anteroseptal and basal anterior segments, significant reductions were obtained on the 5-point scoring system for perfusion defect severity in segments and in the summed rest scores. No significant differences were observed between the two groups in the incidence of MACE at 6 months. The safety profile did not differ between 24 and 48 h infusions of tirofiban.

CONCLUSION

The use of tirofiban, when administered at a high bolus dose and maintained for 48 h, was safe and significantly reduced perfusion defect severity in patients with anterior STEMI presenting early after symptom onset and undergoing primary PCI.