Role of tirofiban with dual antiplatelet therapy in patients with STEMI undergoing primary PCI

I read with great interest the manuscript written by Kaymaz et al. (1) entitled “The effects of tirofiban infusion on clinical and angiographic outcomes of patients with STEMI undergoing primary PCI” published in the Anatolian Journal of Cardiology on December 25, 2014 (Epub ahead of print). The article showed that tirofiban in addition to aspirin, highdose clopidogrel, and unfractionated heparin administered prior to primary PCI significantly improves myocardial reperfusion, ST segment resolution, in-hospital mortality, and total mortality rates in patients with STEMI without an increased risk of major bleeding. Several trials performed before the routine use of dual antiplatelet therapy (DAPT), mostly using abciximab, documented clinical benefits of GP IIb/IIIa inhibitors as adjuncts to primary PCI performed with UFH (2). The FINESSE trial found that the routine upstream use of abciximab before primary PCI did not yield clinical benefit but led to an increased risk of bleeding compared with routine use in the catheterization laboratory (3). The FINESSE trial showed that for patients progressing to primary PCI, there does not appear to be any appreciable benefit, but only harm, in starting GP IIb/IIIa inhibitors in the pre-hospital setting. Similarly, Jeremias et al. (4) showed that the routine use of abciximab in patients with STEMI treated with primary stenting may reduce short-term rates of death or reinfarction in patients not administered pre-procedural thienopyridine therapy, but the use of abciximab does not appear to be beneficial in those who receive pre-procedural thienopyridines in a meta-analysis of five randomized trials (4). According to these studies, the 2012 ESC guideline defined that there is no definitive answer regarding the current role of the routine use of GP IIb/IIIa inhibitors in primary PCI in the era of potent DAPT, particularly when prasugrel or ticagrelor is used (5). On the other hand, recent studies (6, 7) of tirofiban with DAPT in STEMI support the findings of Kaymaz et al. (1) Tirofiban administered with primary PCI following the administration of 600 mg clopidogrel improved the primary efficacy outcome at 30-day and 1-year follow-up without an increase in major bleeding. Zhu et al. (7) demonstrated that the upstream use of tirofiban is significantly associated with an increased incidence of spontaneous reperfusion and a decreased incidence of MACE at 30-day as well as 90-day follow-up in patients treated with primary PCI for STEMI. I appreciate the authors for highlighting the use of tirofiban with DAPT in STEMI patients. There are some issues that need to be clarified to obtain more data from the study. The intracoronary use of GP IIb/IIIa inhibitors has been tested in several small studies, and it is associated with some benefits (7). Did you apply intracoronary tirofiban in the peri-Tiro group in any patients? Was thrombus aspiration performed with a manual aspiration catheter in any study patient? If not, why? Why did you prefer “pain-to-balloon time” instead of “first medical contact (FMC) to balloon time”? Can you provide additional information about the effect of tirofiban on the noreflow phenomenon in your study? Did patients with a high thrombus burden or no-reflow undergo repeat angiography after tirofiban infusion? Was the tirofiban infusion dose reduced in patients with renal insufficiency? Finally, do patients visiting non-PCI hospitals within 4 h of symptom onset and requiring transfer have a survival benefit from the use of abciximab in post-hoc subset analysis of the FINESSE trial (8)? Is there a correlation between the benefits of tirofiban and pain-to-balloon time in your study?