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September 17, 2003

Glycoprotein IIb/IIIa Inhibition in Percutaneous Coronary Interventions

Author Affiliations

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;290(11):1451. doi:10.1001/jama.290.11.1451-a

In Reply: Dr Sharma and colleagues point out that we excluded patients with acute myocardial infarction from our trial, as has been the policy for virtually all broad-based trials of PCI. Ongoing myocardial infarction at the time of enrollment influences both the administration of other antithrombotic agents prior to randomization and the ascertainment of clinical end points, essentially precluding diagnosis of periprocedural myocardial necrosis. For these and other reasons, patients with acute infarction are usually studied in trials specifically dedicated to percutaneous revascularization in that setting. As we noted in our article, "patients with acute myocardial infarction or unstable ischemic syndromes requiring empiric Gp IIb/IIIa inhibition were not included in the Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE)–2 trial, and the results of this trial should not be interpreted to suggest that Gp IIb/IIIa blockade should be supplanted in those patients." Future studies are planned, however, to assess the relative efficacy of bivalirudin vs heparin and the role of Gp IIb/IIIa blockade specifically among patients with acute ischemic syndromes. We also point out that the extent of thrombus burden has never been shown to influence the magnitude of periprocedural or long-term benefit from Gp IIb/IIIa inhibition.1