What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Cardiogenic shock complicating acute myocardial infarction (n=1216). Intervention: Glycoprotein IIb/IIIa inhibitors (GPI) vs. Standard care without GPI. Primary outcome: 30-day mortality (OR 0.55, 95% CI 0.35-0.85, p=0.007).

November 11, 2020Open Access

Glycoprotein IIb/IIIa inhibitors for cardiogenic shock complicating acute myocardial infarction: a systematic review, meta-analysis, and meta-regression

Key Result

Glycoprotein IIb/IIIa inhibitors reduced the odds of 30-day mortality by 45% (OR 0.55) compared to standard care in patients with cardiogenic shock complicating acute myocardial infarction.

Study Design

Type

Meta-Analysis (n=1,216)

Structured PICO

Does adjunctive use of glycoprotein IIb/IIIa inhibitors reduce mortality in patients with acute myocardial infarction complicated by cardiogenic shock?

Population

1,216 patients across 7 studies (1 RCT, 6 observational) with acute myocardial infarction complicated by cardiogenic shock. Mean age 66.6-69.1 years.

Intervention

Glycoprotein IIb/IIIa inhibitors (abciximab, eptifibatide, or tirofiban) as an adjunct to standard treatment

Comparator

Standard care without routine glycoprotein IIb/IIIa inhibitors

Outcome

30-day mortalityhard clinical

Adjunctive use of glycoprotein IIb/IIIa inhibitors in cardiogenic shock complicating acute MI is associated with improved short- and long-term survival and higher rates of TIMI 3 flow without increasing major bleeding, though this benefit is primarily driven by older studies.

Main Result

Effect estimate: OR 0.55 (95% CI 0.35-0.85)

Absolute Event Rate: 37% vs 50%

p-value: p=0.007

Limitations

Most included studies had an observational design
Heterogeneity in the definitions of cardiogenic shock across studies
Inclusion of patients admitted with cardiac arrest but not shock in some studies
Most studies were conducted in the clopidogrel era and may reflect different standards of care regarding antiplatelet therapy and revascularization strategies

Abstract

Abstract Background Cardiogenic shock complicates 5–10% of myocardial infarction (MI) cases. Data about the benefit of glycoprotein IIb/IIIa inhibitors (GPI) in these patients is sparse and conflicting. Methods We performed a systematic review, meta-analysis, and meta-regression of studies assessing the impact of GPI use in the setting of MI complicated cardiogenic shock on mortality, angiographic success, and bleeding events. We systematically searched for studies comparing GPI use as adjunctive treatment versus standard care in this setting. Random-effects meta-analysis and meta-regression were performed. Results Seven studies with a total of 1216 patients (GPI group, 720 patients; standard care group, 496 patients) were included. GPI were associated with a 45% relative reduction in the odds of death at 30 days (pooled OR 0.55; 95% CI 0.35–0.85; I 2 = 57%; P = 0.007) and a 49% reduction in the odds of death at 1 year (pooled OR 0.51; 95% CI 0.32–0.82; I 2 = 58%; P = 0.005). Reduction in short-term mortality seemed to be more important before 2000, as this benefit disappears if only the more recent studies are analyzed. GPI were associated with a 2-fold increase in the probability of achieving TIMI 3 flow (pooled OR, 2.05; 95% CI 1.37–3.05; I 2 = 37%, P = 0.0004). Major bleeding events were not increased with GPI therapy (pooled OR, 1.0; 95% CI 0.55–1.83; I 2 = 1%, P = 0.99). Meta-regression identified that patients not receiving an intra-aortic balloon pump seemed to benefit the most from GPI use ( Z = − 1.57, P = 0.005). Conclusion GPI therapy as an adjunct to standard treatment in cardiogenic shock was associated with better outcomes, including both short- and long-term survival, without increasing the risk of bleeding.

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