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Guideline-recommended glycoprotein IIb/IIIa inhibition is underused in high-risk patients with non–ST-segment-elevation acute coronary syndromes (NSTEACS), perhaps because of unresolved issues regarding drug choice, optimal timing and dosage, costs, the equivalence of alternative platelet inhibitors, and whether to initiate GPIIb/IIIa inhibition upstream (in all high-risk patients in the CCU) or downstream (before PCI in the cath lab). Two new studies, neither sponsored by industry, focus on the upstream/downstream dilemma.
In an open-label randomized trial from Italy, 93 high-risk NSTEACS patients (mean age, 65) undergoing PCI received upstream standard-dose tirofiban, downstream high-dose tirofiban, or downstream abciximab. Significantly f…