n N=483 n Abciximab in the ER or cath lab u 30-day MACEAny drug Int to treat (n=409) (n=483) Control Abciximab P value n 6-month MACE: no difference Early vs. late : RAPPORT Brenner & al. Am J Cardiol. 1999;84: ReoPro in Acute myocardial infarction and Primary PTCA Organization Randomized Trial

Early vs. late : ON-TIME 43,0% 34,2% 0% 20% 40% EarlyLate or No Early tirofiban administration was significantly associated with a greater frequency of TIMI 3 flow in the infarct- related artery before PCI. Similarly, incidence of myocardial perfusion grade 2-3 before PCI was significantly higher in the early treatment group (p=0.04). There were no differences in the two treatment arms in TIMI 3 flow after PCI, ST segment resolution, or 30-day clinical endpoints including death, reinfarction, stroke, and major bleeding. TIMI 2-3 Flow in Culprit Artery Pre-PCI p = 0.04 VantHof & al. Eur Heart J 2004;25:807

Early vs. late : INTAMI 34,0% 10,2% 0% 5% 10% 15% 20% 25% 30% 35% EarlyLate or No Early eptifibatide administration was significantly associated with a greater frequency of TIMI 3 flow in the infarct- related artery before PCI. Similarly, incidence of TIMI myocardial perfusion grade 3 before PCI was significantly higher in the early treatment group (p=0.01). There were no differences in the two treatment arms in TIMI 3 flow after PCI, ST segment resolution, or 30-day clinical endpoints including death, reinfarction, stroke, and major bleeding. TIMI 3 Flow in Culprit Artery Pre-PCI p = 0.01 Zeymzer & al. Eur Heart J 2005;26:1971

Early vs. late : Admiral Montalescot & al. N Engl J Med 2001;344:1895

Early vs. late : Admiral Montalescot & al. N Engl J Med 2001;344:1895

Corrélation délai AntiGP-PCI et Mortalité à 30j Earlier is better ! Admiral, Erami, On time, Relax, Reomobile, Tiger, Titan, Zorma & al - N=875 pts Anti Gp to PCI time (min) 30 days mortality (%)

Corrélation délai AntiGP-PCI et Mortalité à 30j Earlier is better ! Admiral, Erami, On time, Relax, Reomobile, Tiger, Titan, Zorma & al - N=875 pts 4.9% 3.1% 1.8%

Les questions n Chez les patients bénéficiant dune ACT première pour IDM ST +, une administration précoce dantiGP2b3 apporte-t-elle un bénéfice par rapport à une utilisation péri-PCI en terme de : u paramètres angiographiques : OUI u critères pronostiques intermédiaires : OUI u MACEs (décès, ré-IDM) : OUI…probablement

RECOMMANDATIONS ESC 2003 I : Current data support the use of abciximab in combination with low dose heparine in primary coronary angioplasty ACC/AHA 2004 IIA : It is reasonable to start treatment with abciximab as early as possible before primary PCI (with or without stenting) in patients with STEMI IIB : Treatment with tirofiban or eptifibatide may be considered before primary PCI (with or without stenting) in patients with STEMI

Les questions n Faut-il initier un traitement par anti GP2b3a en préhospitalier : u Dans linfarctus ST + en association avec la thrombolyse : NON u Dans linfarctus ST + avant angioplastie première : OUI u Dans les SCA non ST+ ?

Les questions n Faut-il initier un traitement par anti GP2b3a en préhospitalier : u Dans linfarctus ST + en association avec la thrombolyse : NON u Dans linfarctus ST + avant angioplastie première : OUI u Dans les SCA non ST+ ?

Bénéfice des AntiGP dans les SCA non ST+ Boersma & al.Lancet 2002; 359: 189–98

Bénéfice des AntiGP dans les SCA non ST+ Boersma & al.Lancet 2002; 359: 189–98

Stratification / Troponine Morrow et al. JAMA 2001;286:2405–12.

Stratification / Score de risque Lanuzzi et al. Am Heart J 2003;146:764–74.

Bénéfice des AntiGP dans les SCA non ST+ Boersma & al.Lancet 2002; 359: 189–98

RECOMMANDATIONS ESC 2003 I : High risk patients require aggressive antiplatelet treatment with blockade of the 3 principal pathways (ASA, clopidogrel, GpIIb/IIIa) with rapid invasive strategy prepared by upstream treatment. ACC/AHA 2002 I : A platelet GP IIb/IIIa antagonist, should be administered, in addition to aspirin and heparin, to patients in whom catheterization and PCI are planned. The GP IIb/IIIa antagonist may also be administered just prior to PCI. IIa : A platelet GP IIb/IIIa antagonist should be administered to patients already receiving heparin, aspirin, and clopidogrel in whom catheterization and PCI are planned. The GP IIb/IIIa antagonist may also be administered just prior to PCI

Early vs. Late : EVEREST Bolognese & al. J Am Coll Cardiol 2006;47:522– 8

Early vs. Late : EVEREST Bolognese & al. J Am Coll Cardiol 2006;47:522– 8

Early vs. Late : EVEREST Bolognese & al. J Am Coll Cardiol 2006;47:522– 8

Early vs. Late : EVEREST Bolognese & al. J Am Coll Cardiol 2006;47:522– 8 This pilot study shows that in high-risk NSTE-ACS, an early invasive strategy with upstream tirofiban is associated with improved tissue-level perfusion and attenuated myocardial damage, compared with an early invasive strategy with downstream HDB tirofiban or abciximab.

Early vs. Late : Acuity Timing Trial n Population : 9207 pts with moderate- and high-risk ACS undergoing an invasive strategy n Method : random assignation to routine upstream (n=4605) or downstream selective (n=4602) Gp IIb/IIIa inhibitor administration n End point : death, MI, or unplanned revascularization for ischemia n Treatments : Stone et al. JAMA ;297: UpstreamDownstreamP Any GP2b3a (%)9856< Eptifibatide (%)6557 Tirofiban (%)34 4 < 0.01 Abciximab (%) 133 GP-PCI time (h)4.10.6< Duration (h)1813 < 0.01 PrePCI ASA+CLO (%)6463 NS

Early vs. Late : Acuity Timing Trial n 30-D results Stone et al. JAMA ;297: % UpstreamDownstreamP Death+MI+Rev7.17.9NS Death from any cause1.31.5NS MI4.95.0NS Unplanned revasc NS Major bleeding HIC NS Retroperitoneal0.60.5NS Access site2.72.4NS B. requiring surgery0.50.7NS Blood transfuson Minor bleeding

â Men0.08 â 65 years0.08 â ST depression0.02 â Planned PCI0.15 â Men0.08 â 65 years0.08 â ST depression0.02 â Planned PCI0.15

Early vs. Late : EARLY-ACS To demonstrate the superiority of early eptifibatide compared to placebo (with provisional use of eptifibatide in the cath lab) in reducing the composite of death, MI, recurrent ischemia, and thrombotic bail-out within 96 hours in patients with high-risk NSTE ACS managed with an early invasive strategy (N=10500).

Les questions n Faut-il initier un traitement par anti GP2b3a en préhospitalier : u Dans linfarctus ST + en association avec la thrombolyse : NON u Dans linfarctus ST + avant angioplastie première : OUI u Dans les SCA non ST+ : ?

Conclusion Pour langioplastie première, nous proposons ladministration danti-GP IIb/IIIa (ABCIXIMAB en priorité) en pré hospitalier, associé à 300 mg de CLOPIDOGREL, 250 à 500 mg dASPIRINE quel que soit lâge et lHNF. Si un anti-GP IIb/IIIa ne peut être utilisé, nous proposons ladministration de 600 mg de CLOPIDOGREL le plus rapidement possible et quel que soit lâge.