DALLAS -- For smaller community hospitals that routinely transfer their sicker heart attack patients to larger tertiary care facilities for advanced treatment, the immediate use of a new anti-platelet drug improves the odds that the patient will not die or suffer a second heart attack within 30 days.
Based on the results of their so-called "Drip and Ship" study, researchers from the Duke Clinical Research Institute (DCRI), further recommend that these smaller hospitals immediately begin infusion of the drug eptifibatide (trade name Integrilin) in their suspected heart attack patients with unstable angina, regardless of whether the hospital transfers the sicker patients to larger facilities.
The international 11,000-patient PURSUIT trial, the results of which were published this summer in the New England Journal of Medicine, demonstrated that eptifibatide significantly reduced the 30-day incidence of death or heart attack in heart patients who were admitted to the hospital with unstable coronary syndromes.
Since the majority of these patients are first seen in smaller community hospitals, the DCRI researchers wanted to know if it mattered when the drug was administered -- before or after transfer.
"For these smaller hospitals, the message is clear -- begin the drug immediately," said study author Dr. Adam Greenbaum. "Furthermore, the decision of whether or not to transfer should be based on clinical considerations. In some cases, it appears that starting the drug at the smaller hospital may even alleviate the need to transfer altogether."
Greenbaum, a cardiology fellow at the DCRI, prepared the results of his study for presentation Tuesday (Nov. 10) at the 71st scientific sessions of the American Heart Association meeting.
Eptifibatide, a class of drug known as platelet glycoprotein IIb/IIIa inhibitors, interrupts the cascade of events that causes platelets circulating in the blood to clump together and form a clot at the site of an atherosclerotic plaque.
The drug is infused continually in patients for a number of days until the threat of blockage diminishes. According to Greenbaum, the drug is easy to administer, which could make it more attractive to smaller hospitals that may not have much experience with this class of drug for heart patients.
"For large hospitals with active cardiac catheterization laboratories and other interventional capabilities, patients are given the drug right away, and they do well," Greenbaum said. "The problem is that the majority of people in the U.S. and the world first come to hospitals that don't have these capabilities."
To see if eptifibatide had additional benefit when administered before transfer, the researchers compared the outcomes of the 429 PURSUIT patients who were transferred to larger hospitals from smaller hospitals to the 2,009 patients who were admitted directly to the larger institutions without being transferred.
As it turned out, significantly fewer patients who had been randomized to eptifibatide ended up being transferred. Since the decision of whether or not to transfer was made after the randomization of the patient to drug or placebo, the researchers concluded that in many of the eptifibatide cases, the drug improved the status of patients to the point that they were not then considered sick enough for transfer.
This alone may improve outcomes and lower health care costs, Greenbaum added.
Joining Greenbaum in the study were, from Duke, Dr. Robert Harrington, Dr. Michael Hudson, Cynthia MacAulay, Lisa Berdan, Dr. A Michael Lincoff, Dr. Robert Califf and Dr. E. Magnus Ohman; Dr. Gary Miller, Danville, Va.; and Dr. Alan Guerci, Roslyn, N.Y.