Skip to main content
SpringerLink
Log in

Unstable Angina: PARAGON, PURSUIT, PRISM, and PRISM-PLUS

  • Chapter
Platelet Glycoprotein IIb/IIIa Inhibitors in Cardiovascular Disease

Part of the book series: Contemporary Cardiology ((CONCARD))

  • 54 Accesses

Abstract

Unstable angina is part of the acute coronary syndrome (ACS) spectrum and is adjacent to non-Q-wave myocardial infarction (MI) and slightly more distantly related to Q-wave MI. The diversity of conditions leading to unstable angina, as well as the varying symptoms upon presentation, have made the definition and classification of unstable angina difficult (1). The Global Unstable Angina Registry And Treatment Evaluation (GUARANTEE) study reported that one-third of hospitalized patients had new or accelerated symptoms associated with exertion, whereas two-thirds had rest angina (2). This distinction is important because patients with exertional angina may have a gradual worsening of an underlying atherosclerotic coronary arterial narrowing as opposed to those with rest angina who have an abrupt reduction in myocardial perfusion because of a ruptured plaque (Chapter 1). Angina at rest is often associated with electrocardiographic changes of ischemia and shares a similar underlying pathophysiologic mechanism to threatened vessel closure following percutaneous coronary angioplasty, i.e., plaque disruption. Whether spontaneous or as a result of angioplasty, plaque rupture leads to exposure of the coronary arterial subendothelial components, platelet activation, and thrombus formation.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 74.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Fuster V, Chesebro JH. Mechanisms of unstable angina. N Engl J Med 1986; 315: 1023–1024.

    Article  PubMed  CAS  Google Scholar 

  2. Moliterno DJ, Aguirre FV, Cannon CP, Every NP, Granger CB, Sapp SK, Booth JE, Fergsuon JJ, for the GUARANTEE Investigators. The Global unstable angina registry and treatment evaluation. Circulation 1996; 94: I - 195.

    Google Scholar 

  3. Willerson JT, Golino P, Eidt J, Campbell WB, Buja LM. Specific platelet mediators and unstable coronary artery lesions: experimental evidence and potential clinical implications. Circulation 1989; 80: 198–205.

    Article  PubMed  CAS  Google Scholar 

  4. Coller BS. The role of platelets in arterial thrombosis and the rationale for blockade of platelet GP IIb/ IIIa receptors as antithrombotic therapy. Eur Heart J 1995; 16: 11–15.

    Article  PubMed  CAS  Google Scholar 

  5. Théroux P, Ouimet H, McCans J, Latour J, Joly P, Levy G, Pelletier E, Juneau M, Stasiak J, de Guise P, Pelletier GB, Rinzler D, Waters DD. Aspirin, heparin, or both to treat acute unstable angina. N Engl J Med 1988; 319: 1105–1111.

    Article  PubMed  Google Scholar 

  6. The RISC Group. Risk of myocardial infarction and death during treatment with low dose aspirin and intravenous heparin in men with unstable coronary artery disease. Lancet 1990; 336: 827–830.

    Article  Google Scholar 

  7. Wallentin LC, and the Research Group on Instability in Coronary Artery Disease in Southeast Sweden. Aspirin (75 mg/day) after an episode of unstable coronary artery disease: long-term effects on the risk for myocardial infarction, occurrence of severe angina and the need for revascularization. J Am Coll Cardiol 1991; 18: 1587–1593.

    Google Scholar 

  8. Cairns JA, Gent M, Singer J, Finnie KJ, Frogatt GM, Holder DA, Jablonsky G, Kostuk WJ, Melendez LJ, Myers MG, Sackett DL, Sealey BJ, Tanser PH. Aspirin, sulfinpyrazone, or both in unstable angina. N Engl J Med 1985; 313: 1369–1375.

    Article  PubMed  CAS  Google Scholar 

  9. Lewis HDJ, Davis JW, Archibald DG, Steinke WE, Smitherman TC, Doherty JE, Schnaper HW, LeWinter MW, Linares E, Pouget JM, Sabharwal SC, Chesler E, DeMots H. Protective effects of aspirin against acute myocardial infarction and death in men with unstable angina. N Engl J Med 1983; 309: 396–403.

    Article  PubMed  Google Scholar 

  10. Antiplatelet Trialists’ Collaboration. (1994) Collaborative overview of randomised trials of antiplatelet therapy. I. Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Br Med J 1994; 308: 81–106.

    Google Scholar 

  11. Maffrand JP, Bernat A, Delebasse D, Defreyen G, Cazenave JP, Gordon JL. ADP plays a key role in thrombogenesis in rats. Thromb Haemost 1988; 59: 225–230.

    PubMed  CAS  Google Scholar 

  12. De Minno G, Cerbone AM, Mattioli PL, Turco S, Iovine C, Mancini M. Functionally thrombosthenic state in normal platelets following the administration of ticlopidine. J Clin Invest 1985; 75: 328–338.

    Article  PubMed  Google Scholar 

  13. Panak E, Maffrand JP, Picard-Fraire C, Vallee E, Blanchard J, Roncucci R. (1983) Ticlopidine: a promise for the prevention and treatment of thrombosis and its complications. Haemostasis 1983; 13 (Suppl 1): 1–54.

    PubMed  Google Scholar 

  14. Balsano F, Rizzon P, Violi F, Scrutinio D, Cimminiello C, Aguglia F, Pasotti C, Rudelli G, and the Studio della Ticlopidina nell’Angina Instabile Group. Antiplatelet treatment with ticlopidine in unstable angina. A controlled multicenter clinical trial. Circulation 1990; 82: 17–26.

    Google Scholar 

  15. CAPRIE Steering Commitee A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996; 348: 1329–1339.

    Article  Google Scholar 

  16. The PARAGON Investigators. An international, randomized, controlled trial of lamifiban, a platelet glycoprotein IIb/IIIa inhibitor, heparin, or both in unstable angina. Circulation 1998; 97: 2386–2395.

    Article  Google Scholar 

  17. The Platelet Receptor Inhibition in Ischemic Syndrome Management (PRISM) Study Investigators. A comparison of aspirin plus tirofiban with aspirin plus heparin for unstable angina. N Engl J Med 1998; 338: 1498–1505.

    Article  Google Scholar 

  18. The Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) Study Investigators. Inhibition of the platelet glycoprotein IIb/ IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. N Engl J Med 1998; 338: 1488–1497.

    Article  Google Scholar 

  19. The PURSUIT Trial Investigators. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. N Engl J Med 1998; 339: 436–463.

    Article  Google Scholar 

  20. The EPIC Investigators. Use of a monoclonal antibody directed against the platelet glycoprotein IIb/ IIIa receptor in high-risk coronary angioplasty. N Engl J Med 1994; 330: 956–961.

    Article  Google Scholar 

  21. The EPILOG Investigators. Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization. N Engl J Med 1997; 1689–1696.

    Google Scholar 

  22. Lincoff AM, Califf RM, Anderson KM, Weisman HF, Aguirre FV, Kleiman NS, Harrington RA, Topol EJ, for the EPIC Investigators. Evidence for prevention of death and myocardial infarction with platelet membrane glycoprotein IIb/IIIa receptor blockade by abciximab (c7E3 Fab) among patients with unstable angina undergoing percutaneous coronary revascularization. J Am Coll Cardiol 1997; 30: 149–156.

    Article  PubMed  CAS  Google Scholar 

  23. Topol EJ, Ferguson JJ, Weisman HF, Tcheng JE, Ellis SG, Kleiman NS, Ivanhoe RJ, Wang AL, Miller DP, Anderson KM, Califf RM, on behalf of the EPIC Investigators. Long term protection from myocardial ischemic events in a randomized trial of brief integrin 03 blockade wwith percutaneous intervention. J Am Med Assoc 1997; 278: 479–484.

    Article  CAS  Google Scholar 

  24. The CAPTURE Investigators. Randomised placebo-controlled trial of abciximab before and during coronary interventions in refractory unstable angina: the CAPTURE study. Lancet 1997; 349: 1429–1435.

    Article  Google Scholar 

  25. Théroux P, Kouz S, Roy L, Knudtson ML, Diodati JG, Marquis J-F, Nasmith J, Fung AY, Boudreault J-R, Delage F, Dupuis R, Kells C, Bokslag M, Steiner B, Rapold HJ, on Behalf of the Investigators. Platelet membrane receptor glycoprotein IIb/IIIa antagonism in unstable angina. The Candian Lamifiban Study. Circulation 1996; 94: 899–905.

    Article  PubMed  Google Scholar 

  26. Topol EJ, Califf RM, Van de Werf F, Simoons M, Hampton J, Lee KL, White H, Simes J, Armstrong PW, for the Virtual Coordinating Center for Global Collaborative Cardiovascular Research (VIGOUR). Perspectives on large-scale cardiovascular clinical trials for the new millennium. Circulation 1997; 95: 1072–1082.

    Google Scholar 

  27. Oler A, Whooley MA, Oler J, Grady D. Adding heparin to aspirin reduces the incidence of myocardial infacrtion and death in patients with unstable angina: a meta-analysis. J Am Med Assoc 1996; 2276: 811–815.

    Google Scholar 

  28. Théroux P, White H, David D, Van de Werf F, Nienaber CA, Charbonnier B, Erhardt L, Gill J, Hillis WS, Jennings G, Tan L-B, Deschenes N, Fitzpatrick V, Sax F. A heparin-controlled study of MK-383 in unstable angina. Circulation 1994; 90: I - 231.

    Google Scholar 

  29. Schulman SP, Goldschmidt-Clermont PJ, Topol EJ, Califf RM, Navetta FI, Willerson JT, Chandra NC, Guerci AD, Ferguson JJ, Harrington RA, Lincoff AM, Yakubov SJ, Bray PF, Bahr RD, Wolfe CL, Yock PG, Anderson HV, Nygaard TW, Mayson SJ, Effron MB, Fatterpacker A, Raskin S, Smith J, Brashears L, Gottdiener P, duMee C, Kitt M, Gerstenblith G. Effects of integrelin, a platelet glycoprotien IIb/IIIa receptor antagonist, in unstable angina: a randomized multicenter trial. Circulation 1996; 94: 2083–2089.

    Article  PubMed  CAS  Google Scholar 

  30. Phillips DR, Teng W, Arfsten A, Nannizzi-Alaimo L, White MW, Longhurst C, Shattil SJ, Randolph A, Jakubowski JA, Jennings LK, Scarborough RM. Effect of Ca2+ on GP IIb-IIIa binding and inhibition of platelet aggregation by reductions in the concentration of ionized calcium in plasma anticoagulated with citrate. Circulation 1997; 96: 1488–1494.

    Article  PubMed  CAS  Google Scholar 

  31. Moliterno DJ, Topol EJ. Meta-analysis of platelet GP IIb/IIIa antagonist randomized clinical trials: consistent, durable, salutary Effects. Circulation 1997; 96: I - 475.

    Google Scholar 

  32. Topol EJ. Toward a new frontier in myocardial reperfusion therapy: emerging platelet preeminence. Circulation 1997; 97: 211–218.

    Article  Google Scholar 

  33. Kong DF, Califf RM, Miller DP, Moliterno DJ, White HD, Harrington RA, Tcheng JE, Lincoff AM, Hasselblad V, Topol EJ. Clinical outcomes of therapeutic agents that block the platelet glycoprotein inhibitor integrin in ischemic heart disease. Circulation 1998; 98: 2829–2835.

    Article  PubMed  CAS  Google Scholar 

  34. Steiner B, Hofer U, Wittke B, Topol EJ, Califf RM, Harrington R, Armstrong P, Van de Werf F, Moliterno DJ. Plasma concentrations of lamifiban and glycoprotein IIb-IIIa receptor occupancy best predict clinical outcome in patients with unstable angina: results from PARAGON A. Eur Heart J 1998; 19 (abstsr. suppl.): 598.

    Google Scholar 

Download references

Authors
  1. David J. Moliterno MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Harvey D. White MB DSC
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Experimental Interventional Laboratory, Joseph J. Jacobs Center for Thrombosis and Vascular Biology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

    A. Michael Lincoff MD (Associate Professor of Medicine. Director) (Associate Professor of Medicine. Director)

  2. Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

    A. Michael Lincoff MD (Associate Professor of Medicine. Director) & Eric J. Topol MD (Professor of Medicine, Chairman. Director) (Associate Professor of Medicine. Director) &  (Professor of Medicine, Chairman. Director)

  3. Joseph J. Jacobs Center for Thrombosis and Vascular Biology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

    Eric J. Topol MD (Professor of Medicine, Chairman. Director) (Professor of Medicine, Chairman. Director)

Rights and permissions

Reprints and permissions

Copyright information

© 1999 Springer Science+Business Media New York

About this chapter

Cite this chapter

Moliterno, D.J., White, H.D. (1999). Unstable Angina: PARAGON, PURSUIT, PRISM, and PRISM-PLUS. In: Lincoff, A.M., Topol, E.J. (eds) Platelet Glycoprotein IIb/IIIa Inhibitors in Cardiovascular Disease. Contemporary Cardiology. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-59259-724-6_10

Download citation

  • DOI: https://doi.org/10.1007/978-1-59259-724-6_10

  • Publisher Name: Humana Press, Totowa, NJ

  • Print ISBN: 978-1-4757-6202-0

  • Online ISBN: 978-1-59259-724-6

  • eBook Packages: Springer Book Archive

Publish with us

Policies and ethics

Search

Navigation