Medical Therapy Antiplatelet Agents

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The role of adjunctive pharmacologic therapy in the treatment of patients with acute myocardial infarction has been well studied, although data on gender differences in response to treatment are limited. In general, results of trials performed predominantly in men and therefore, treatment recommendations, have been extrapolated to women. It should be noted, however, that women with a high baseline risk profile have the most to gain from risk reduction therapy.

Although few studies addressed the efficacy of aspirin for primary prevention in women, a meta-analysis of randomized trials of aspirin therapy revealed a 25% reduction in the risk of subsequent cardiovascular events in both women and men with vascular disease (38). Further review revealed that only one-third of postmenopausal women with cardiovascular disease were taking daily aspirin, and, the majority of these women were doing so for primary prevention (39). In the Second National Registry of Myocardial Infarction (NRMI 2), women were less likely to receive aspirin both on hospital admission and at discharge than their male counterparts (40).

Recently, inhibitors of the glycoprotein IIb/IIIa receptor, a receptor on the platelet surface that mediates platelet aggregation, have been developed and, in clinical trials, have demonstrated efficacy in the initial medical stabilization of patients with acute coronary syndromes and as an adjunct to percutaneous revascularization procedures (41). As it has also been suggested that there is a gender-based difference in platelet function and women are believed to have hyperreactive platelets, it therefore follows that they should experience a greater benefit from these platelet inhibitors (42).

To evaluate the role of glycoprotein IIb/IIIa receptor antagonists in the medical management of acute coronary syndromes, the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISMPLUS) trial randomized 1915 patients with acute coronary syndromes to tirofiban or placebo and demonstrated a 32% reduction in the composite endpoint of death, myocardial infarction, refractory ischemia or rehospitalization for recurrent ischemia, at 7 d, a 22% reduction at 30 d, and a 19% decrease at 6 mo in patients treated with tirofiban. Women treated with tirofiban had a 30% reduction in events at 7 d, which was similar to the 27% reduction observed in men (43). Interestingly, these benefits for women were not as readily recognized in the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial. This study randomized 10,948 patients to eptifibatide or placebo treatment groups. Treatment with eptifi-

Stent-placebo

*p=0.02 stent-stent comparison #p=0.004 stent-abciximab vs. balloon-abciximab

40-i

I I Balloon-abciximab w Stent-abciximab

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