Management of patients with non-ST-segment elevation acute coronary syndromes: insights from the PURSUIT trial.

The glycoprotein (GP) IIb-IIIa inhibitor eptifibatide (INTEGRILIN, COR Therapeutics, Inc., South San Francisco, California, and Key Pharmaceuticals, Inc., Kenilworth, New Jersey) is a novel and highly potent antithrombotic agent indicated for the management of patients with non-ST-segment elevation acute coronary syndromes (ACS) and those undergoing percutaneous coronary intervention. The approval of eptifibatide for non-ST-segment elevation ACS was based on the positive results of the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial. With enrollment of almost 11,000 patients, not only is the PURSUIT trial the largest trial of a GP IIb-IIIa inhibitor to date, but it is also the largest clinical study ever conducted in patients with non-ST-segment elevation ACS. The key feature of the PURSUIT trial is that patient management closely resembled standard clinical practice, because decisions about the use and timing of invasive cardiac procedures were made by the individual physicians rather than being prespecified in the study protocol. Eptifibatide therapy was associated with a significant reduction in the incidence of the primary endpoint--a composite of death or myocardial infarction at 30 days (14.2 vs. 15.7% in the placebo group; p = 0.042). Of importance is the fact that the beneficial effect of eptifibatide was independent of the management strategy pursued during study drug infusion (invasive or conservative), and it was achieved with few major safety concerns. These findings demonstrate that the use of eptifibatide should be considered for all patients presenting with signs and symptoms of intermediate- to high-risk non-ST-segment elevation ACS.