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Li Y, Li J, Guan C, Su S, Wang Z, Liu H, Yang Y, Gao R, Yuan J, Zhao X. One-year clinical outcomes of bivalirudin versus unfractionated heparin in patients with type 2 diabetes undergoing elective percutaneous coronary intervention. Diabetes Metab Syndr 2023; 17:102858. [PMID: 37776692 DOI: 10.1016/j.dsx.2023.102858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Patients with diabetes and coronary artery disease have a higher risk of bleeding and thrombotic events. However, data on the safety and efficacy of bivalirudin in these patients undergoing elective percutaneous coronary intervention (PCI) are lacking. METHODS 1152 patients undergoing elective PCI anticoagulated with bivalirudin and 10,250 patients anticoagulated with unfractionated heparin (UFH) (with or without glycoprotein IIb/IIIa inhibitors [GPI]) were performed propensity-score matching method. The thrombotic endpoint was major adverse cardiovascular and cerebrovascular events (MACCE). The bleeding endpoint was according to the Bleeding Academic Research Consortium (BARC) 2, 3 or 5 bleeding. RESULTS Finally, 376 (bivalirudin group) and 878 (UFH group) patients with type 2 diabetes (T2D) were enrolled. After one-year follow-up, there were 130 (10.4%) MACCE and 27 (2.2%) bleeding events occurred. Multivariate COX regression analysis showed no significant difference for MACCE between bivalirudin group and UFH group (P > 0.05). Further analysis showed that there was a reduction in the risk of myocardial infarction (MI) between two groups (Hazard ratio [HR] = 0.199, 95% confidence interval [CI]: 0.047-0.845, P = 0.029), but not in the risk of death, revascularization, stent thrombosis or stroke (all P > 0.05). As for BARC 2, 3 or 5 bleeding, no significant difference was found between two groups (P > 0.05). CONCLUSIONS Although diabetes is considered a high-risk factor for poor prognosis, compared with UFH (with or without GPI), bivalirudin did not increase the risk of MACCE and even decreased the risk of MI in patients with T2D undergoing elective PCI, while the risk of bleeding was similar between two groups.
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Affiliation(s)
- Yulong Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Jiawen Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Changdong Guan
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Shuhong Su
- Department of Cardiology, Xinxiang Central Hospital, Xinxiang, 453000, Henan Province, China
| | - Zhifang Wang
- Department of Cardiology, Xinxiang Central Hospital, Xinxiang, 453000, Henan Province, China
| | - Haiwei Liu
- Department of Cardiology, Northern Theatre General Hospital, Shenyang, 110016, Liaoning Province, China
| | - Yuejin Yang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Runlin Gao
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Jinqing Yuan
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Xueyan Zhao
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
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Wu Z, Meng P, Guo Y, You W, Wu X, Ye F. Prolonged infusion of bivalirudin after elective percutaneous coronary intervention protects against procedural myocardial injury (a COBER study)-a randomized trial. Sci Rep 2023; 13:6667. [PMID: 37095298 PMCID: PMC10126106 DOI: 10.1038/s41598-023-34008-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 04/22/2023] [Indexed: 04/26/2023] Open
Abstract
Procedural myocardial injury (PMI), which is the most common complication of elective percutaneous coronary intervention (ePCI), is associated with future adverse cardiac events. In this randomized pilot trial, we assessed the effects of prolonged use of the anti-coagulant bivalirudin on PMI after ePCI. Patients undergoing ePCI were randomized into the following two groups: the bivalirudin use during operation group (BUDO, 0.75 mg/kg bolus plus 1.75 mg/kg/h) and the bivalirudin use during and after operation for 4 h (BUDAO, 0.75 mg/kg bolus plus 1.75 mg/kg/h). Blood samples were collected before and 24 h after ePCI (per 8 h). The primary outcome, PMI, was defined as an increase in post-ePCI cardiac troponin I (cTnI) levels of > 1 × 99th% upper reference limit (URL) when the pre-PCI cTnI was normal or a rise in cTnI of > 20% of the baseline value when it was above the 99th percentile URL, but it was stable or falling. Major PMI (MPMI) was defined as a post-ePCI cTnI increase of > 5 × 99th% URL. A total of 330 patients were included (n = 165 per group). The incidences of PMI and MPMI were not significantly higher in the BUDO group than in the BUDAO group (PMI: 115 [69.70%] vs. 102 [61.82%], P = 0.164; MPMI: 81 [49.09%] vs. 70 [42.42%], P = 0.269). However, the absolute change in cTnI levels (calculated as the peak value 24 h post-PCI minus the pre-PCI value) was notably larger in the BUDO group (0.13 [0.03, 1.95]) than in the BUDAO group (0.07 [0.01, 0.61]) (P = 0.045). Moreover, the incidence of bleeding events was similar between the two groups (BUDO: 0 [0.00%]; BUDAO: 2 [1.21%], P = 0.498). Prolonged infusion of bivalirudin for 4 h after ePCI reduces PMI severity without increasing the risk of bleeding.ClinicalTrials.gov.Number: NCT04120961, 09/10/2019.
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Affiliation(s)
- Zhiming Wu
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Rd, Nanjing, 210006, China
| | - Peina Meng
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Rd, Nanjing, 210006, China
| | - Yajie Guo
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Rd, Nanjing, 210006, China
| | - Wei You
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Rd, Nanjing, 210006, China.
| | - Xiangqi Wu
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Rd, Nanjing, 210006, China.
| | - Fei Ye
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Rd, Nanjing, 210006, China.
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Li J, Chen S, Ma S, Yang M, Qi Z, Na K, Qiu M, Li Y, Han Y. Safety and Efficacy of Bivalirudin versus Unfractionated Heparin Monotherapy in Patients with CAD and DM Undergoing PCI: A Retrospective Observational Study. Cardiovasc Ther 2022; 2022:5352087. [PMID: 36530956 PMCID: PMC9729030 DOI: 10.1155/2022/5352087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 11/10/2022] [Accepted: 11/12/2022] [Indexed: 10/24/2023] Open
Abstract
INTRODUCTION Optimal anticoagulants for patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI) are unclear. This retrospective observational study is aimed at evaluating efficacy and safety of bivalirudin versus unfractionated heparin (UFH) monotherapy in patients with DM undergoing PCI. METHODS A total of 3890 diabetic patients receiving PCI in the General Hospital of Northern Theater Command were divided into the bivalirudin group (n = 869) and the UFH group (n = 3021) according to different anticoagulant therapy regimens. Indication for PCI was in accordance with current guidelines including national cardiovascular data registry. The primary endpoint was 30-day net adverse clinical events (NACEs). The secondary endpoints included 30-day major adverse cardiac and cerebral events (MACCEs), bleeding events defined according to the Bleeding Academic Research Consortium (BARC) definition, and stent thrombosis (ST). Patients were matched by propensity score at a ratio of 1 : 1. RESULTS After propensity score matching, the bivalirudin group was associated with a lower incidence of NACEs (3.0% vs. 6.0%, P = 0.003) than the UFH group. The incidence of MACCE (1.7% vs. 3.3%, P = 0.033) was significantly lower in the bivalirudin group, mainly due to a lower mortality rate (0.6% vs. 2.0%, P = 0.010). In addition, patients in the bivalirudin group had less bleeding (1.4% vs. 3.0%, P = 0.022) than those in the UFH group, although BARC 2, 3, and 5 bleeding (0.1% vs. 0.6%, P = 0.218) was numerically lower. CONCLUSION In diabetic patients undergoing PCI, bivalirudin was significantly associated with reduced risks of 30-day NACE and MACCE, mainly driven by the lower rates of bleeding and mortality, compared with heparin monotherapy.
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Affiliation(s)
- Jing Li
- The Graduate School of Harbin Medical University, Harbin, China
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Sanbao Chen
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Sicong Ma
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Mingque Yang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Zizhao Qi
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Kun Na
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Miaohan Qiu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Yaling Han
- The Graduate School of Harbin Medical University, Harbin, China
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
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Li S, Lv D, Liu C, Jia Y. Practicability of Bivalirudin plus Glycoprotein IIb/IIIa Inhibitors in Patients Undergoing Percutaneous Coronary Intervention: A Meta-Analysis. Clin Appl Thromb Hemost 2021; 27:10760296211055165. [PMID: 34775846 PMCID: PMC8597062 DOI: 10.1177/10760296211055165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A variety of antithrombotic drugs are used during percutaneous coronary interventions (PCIs). We aimed to investigate the practicability of the use of bivalirudin and GPIs in patients receiving PCI. We searched 7 of 629 relevant records from PubMed, the Cochrane Library, EMBASE, and Web of Science for randomised controlled trials. There were no significant differences in the rates of major adverse cardiac events (MACE) between bivalirudin plus GPI and heparin (all P > .05). Bivalirudin plus planned GPI was similar to bivalirudin monotherapy in terms of the risk of MACE (risk ratio [RR] = 1.07; 95% confidence interval [CI] = .91 − 1.27; P = .55). Bivalirudin plus provisional GPI was associated with lower bleeding risk (RR = .57; 95% CI = .47 − .69; P < .01) compared to using heparin plus GPI. Compared to bivalirudin alone, bivalirudin plus planned GPI evidently increased bleeding risk (RR = 2.20; 95% CI = 1.73 − 2.79; P < .01). Patients receiving bivalirudin or heparin therapy had semblable efficacy endpoints, but those receiving bivalirudin had a significantly lower bleeding risk. For high-risk bleeding patients, bivalirudin plus provisional GPI can have a better antithrombotic effect than heparin, without increasing the bleeding risk.
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Affiliation(s)
- Senjie Li
- 105862Department of Cardiology, The First Hospital of ShanXi Medical University, Taiyuan, Shanxi, China
| | - Dongqing Lv
- 105862Department of Endocrinology, The First Hospital of ShanXi Medical University, Taiyuan, Shanxi, China
| | - Caihong Liu
- 74648ShanXi Medical University, Taiyuan, Shanxi, China
| | - Yongping Jia
- 105862Department of Cardiology, The First Hospital of ShanXi Medical University, Taiyuan, Shanxi, China
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Bikdeli B, McAndrew T, Crowley A, Chen S, Mehdipoor G, Redfors B, Liu Y, Zhang Z, Liu M, Zhang Y, Francese DP, Erlinge D, James SK, Han Y, Li Y, Kastrati A, Schüpke S, Stables RH, Shahzad A, Steg PG, Goldstein P, Frigoli E, Mehran R, Valgimigli M, Stone GW. Individual Patient Data Pooled Analysis of Randomized Trials of Bivalirudin versus Heparin in Acute Myocardial Infarction: Rationale and Methodology. Thromb Haemost 2020; 120:348-362. [PMID: 31820428 PMCID: PMC7040882 DOI: 10.1055/s-0039-1700872] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Individual randomized controlled trials (RCTs) of periprocedural anticoagulation with bivalirudin versus heparin during percutaneous coronary intervention (PCI) have reported conflicting results. Study-level meta-analyses lack granularity to adjust for confounders, explore heterogeneity, or identify subgroups that may particularly benefit or be harmed. OBJECTIVE To overcome these limitations, we sought to develop an individual patient-data pooled database of RCTs comparing bivalirudin versus heparin. METHODS We conducted a systematic review to identify RCTs in which ≥1,000 patients with acute myocardial infarction (AMI) undergoing PCI were randomized to bivalirudin versus heparin. RESULTS From 738 identified studies, 8 RCTs met the prespecified criteria. The principal investigators of each study agreed to provide patient-level data. The data were pooled and checked for accuracy against trial publications, with discrepancies addressed by consulting with the trialists. Consensus-based definitions were created to resolve differing antithrombotic, procedural, and outcome definitions. The project required 3.5 years to complete, and the final database includes 27,409 patients (13,346 randomized to bivalirudin and 14,063 randomized to heparin). CONCLUSION We have created a large individual patient database of bivalirudin versus heparin RCTs in patients with AMI undergoing PCI. This endeavor may help identify the optimal periprocedural anticoagulation regimen for patient groups with different relative risks of adverse ischemic versus bleeding events, including those with ST-segment and non-ST-segment elevation MI, radial versus femoral access, use of a prolonged bivalirudin infusion or glycoprotein inhibitors, and others. Adherence to standardized techniques and rigorous validation processes should increase confidence in the accuracy and robustness of the results.
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Affiliation(s)
- Behnood Bikdeli
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, United States
- Center for Outcomes Research & Evaluation, Yale School of Medicine, New Haven, CT, United States
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, United States
| | - Thomas McAndrew
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, United States
| | - Aaron Crowley
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, United States
| | - Shmuel Chen
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, United States
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, United States
| | - Ghazaleh Mehdipoor
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, United States
| | - Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, United States
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Yangbo Liu
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, United States
| | - Zixuan Zhang
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, United States
| | - Mengdan Liu
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, United States
| | - Yiran Zhang
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, United States
| | - Dominic P. Francese
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, United States
| | - David Erlinge
- Department of Cardiology, Lund University, Lund, Sweden
| | - Stefan K. James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität, Munich, Germany
| | - Stefanie Schüpke
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität, Munich, Germany
| | - Rod H. Stables
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- University of Liverpool, Liverpool, United Kingdom
| | - Adeel Shahzad
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Philippe Gabriel Steg
- Hôpital Bichat, Paris, France
- Imperial College, Royal Brompton Hospital, London, United Kingdom
| | | | - Enrico Frigoli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roxana Mehran
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, United States
- Icahn School of Medicine at Mount Sinai Hospital, New York, NY, United States
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gregg W. Stone
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, United States
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, United States
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Bhogal S, Mukherjee D, Bagai J, Truong HT, Panchal HB, Murtaza G, Zaman M, Sachdeva R, Paul TK. Bivalirudin Versus Heparin During Intervention in Acute Coronary Syndrome: A Systematic Review of Randomized Trials. Cardiovasc Hematol Disord Drug Targets 2019; 20:3-15. [PMID: 31241442 PMCID: PMC7360918 DOI: 10.2174/1871529x19666190626124057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 05/04/2019] [Accepted: 06/06/2019] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Bivalirudin and heparin are the two most commonly used anticoagulants used during Percutaneous Coronary Intervention (PCI). The results of Randomized Controlled Trials (RCTs) comparing bivalirudin versus heparin monotherapy in the era of radial access are controversial, questioning the positive impact of bivalirudin on bleeding. The purpose of this systematic review is to summarize the results of RCTs comparing the efficacy and safety of bivalirudin versus heparin with or without Glycoprotein IIb/IIIa Inhibitors (GPI). METHODS This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA statements for reporting systematic reviews. We searched the National Library of Medicine PubMed, Clinicaltrial.gov and the Cochrane Central Register of Controlled Trials to include clinical studies comparing bivalirudin with heparin in patients undergoing PCI. Sixteen studies met inclusion criteria and were reviewed for the summary. FINDINGS Several RCTs and meta-analyses have demonstrated the superiority of bivalirudin over heparin plus routine GPI use in terms of preventing bleeding complications but at the expense of increased risk of ischemic complications such as stent thrombosis. The hypothesis of post- PCI bivalirudin infusion to mitigate the risk of acute stent thrombosis has been tested in various RCTs with conflicting results. In comparison, heparin offers the advantage of having a reversible agent, of lower cost and reduced incidence of ischemic complications. CONCLUSION Bivalirudin demonstrates its superiority over heparin plus GPI with better clinical outcomes in terms of less bleeding complications, thus making it as anticoagulation of choice particularly in patients at high risk of bleeding. Further studies are warranted for head to head comparison of bivalirudin to heparin monotherapy to establish an optimal heparin dosing regimen and post-PCI bivalirudin infusion to affirm its beneficial effect in reducing acute stent thrombosis.
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Affiliation(s)
- Sukhdeep Bhogal
- Department of Medicine, Division of Cardiology, East Tennessee State University, Johnson City, TN 37614, United States
| | - Debabrata Mukherjee
- Division of Cardiology, Department of Internal Medicine, Texas Tech University, TX 79409, United States
| | - Jayant Bagai
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Huu T Truong
- University of Arizona College of Medicine, Tucson, AZ 85721, United States
| | - Hemang B Panchal
- Columbia University at Mount Sinai Medical Center, Miami Beach, FL 10027, United States
| | - Ghulam Murtaza
- Department of Medicine, Division of Cardiology, East Tennessee State University, Johnson City, TN 37614, United States
| | | | - Rajesh Sachdeva
- Morehouse School of Medicine, Atlanta, GA 30310, United States
| | - Timir K Paul
- Department of Medicine, Division of Cardiology, East Tennessee State University, Johnson City, TN 37614, United States
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Olmedo W, Villablanca PA, Sanina C, Walker J, Weinreich M, Brevik J, Avendano R, Bravo CA, Romero J, Ramakrishna H, Babaev A, Attubato M, Hernandez-Suarez DF, Cox-Alomar P, Pyo R, Krishnan P, Wiley J. Bivalirudin versus heparin in patients undergoing percutaneous peripheral interventions: A systematic review and meta-analysis. Vascular 2018; 27:78-89. [DOI: 10.1177/1708538118807522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Bivalirudin may be an effective alternative anticoagulant to heparin for use in percutaneous peripheral interventions. We aimed to compare the safety and efficacy of bivalirudin versus heparin as the procedural anticoagulant agent in patients undergoing percutaneous peripheral intervention. Methods For this meta-analysis and systematic review, we conducted a search in PubMed, Medline, Embase, and Cochrane for all the clinical studies in which bivalirudin was compared to heparin as the procedural anticoagulant in percutaneous peripheral interventions. Outcomes studied included all-cause mortality, all-bleeding, major and minor bleeding, and access site complications. Results Eleven studies were included in the analysis, totaling 20,137 patients. There was a significant difference favoring bivalirudin over heparin for all-cause mortality (risk ratio 0.58, 95% CI 0.39–0.87), all-bleeding (risk ratio 0.62, 95% CI 0.50–0.78), major bleeding (risk ratio 0.61, 95% CI 0.39–0.96), minor bleeding (risk ratio 0.66, 95% CI 0.47–0.92), and access site complications (risk ratio 0.66, 95% CI 0.51–0.84). There was no significant difference in peri-procedural need for blood transfusions (risk ratio 0.79, 95% CI 0.57–1.08), myocardial infarction (risk ratio 0.87, 95% CI 0.59–1.28), stroke (risk ratio 0.77, 95% CI 0.59–1.01), intracranial bleeding (risk ratio 0.77, 95% CI 0.29–2.02), or amputations (OR 0.75, 95% CI 0.53–1.05). Conclusion Our meta-analysis suggests that bivalirudin use for percutaneous peripheral interventions is associated with lower all-cause mortality, bleeding, and access site complications as compared to heparin. Further large randomized trials are needed to confirm the current results.
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Affiliation(s)
- Wilman Olmedo
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Pedro A Villablanca
- Division of Cardiology, New York University School of Medicine, New York, NY, USA
| | - Cristina Sanina
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jonathan Walker
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael Weinreich
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jeannine Brevik
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ricardo Avendano
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Claudio A Bravo
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jorge Romero
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic College of Medicine, Scottsdale, AZ, USA
| | - Anvar Babaev
- Division of Cardiology, New York University School of Medicine, New York, NY, USA
| | - Michael Attubato
- Division of Cardiology, New York University School of Medicine, New York, NY, USA
| | - DF Hernandez-Suarez
- Cardiology Section, Medicine Division, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | - P Cox-Alomar
- Section of Cardiology, Division of Medicine, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Robert Pyo
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Prakash Krishnan
- Division of Cardiology, Mount Sinai Medical Center, New York, NY, USA
| | - Jose Wiley
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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8
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Anantha-Narayanan M, Anugula D, Gujjula NR, Reddy YNV, Baskaran J, Kaushik M, Alla VM, Raveendran G. Bivalirudin versus heparin in percutaneous coronary intervention-a systematic review and meta-analysis of randomized trials stratified by adjunctive glycoprotein IIb/IIIa strategy. J Thorac Dis 2018; 10:3341-3360. [PMID: 30069330 DOI: 10.21037/jtd.2018.05.76] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Bivalirudin has been shown to be associated with less major bleeding than heparin in patients undergoing percutaneous coronary intervention (PCI); but the confounding effect of concomitant glycoprotein IIb/IIIa inhibitors (GPI) limits meaningful comparison. We performed a systematic review and meta-analysis to compare bivalirudin to heparin, with and without adjunctive GPI in PCI. Methods We searched PubMed, Cochrane, EMBASE, CINAHL and WOS from January 2000 to December 2017 for clinical trials comparing bivalirudin to heparin, with and without adjunctive GPI during PCI. Cochrane's Q statistics were used to determine heterogeneity. Random effects model was used. Results Twenty-six comparison groups (22 original studies and 4 subgroup analyses) with 53,364 patients were included. Mean follow-up was 192±303 days. There was no difference between the two groups in all-cause mortality [risk ratio (RR: 0.93; 95% CI: 0.82-1.05, P=0.260), target vessel revascularization (TVR) (RR: 1.17; 95% CI: 0.93-1.46, P=0.174) or stroke (RR: 0.91; 95% CI: 0.71-1.18, P=0.490). Major bleeding was lower in the bivalirudin group with concomitant GPI in one or both arms (RR: 0.64; 95% CI: 0.53-0.77, P<0.001) and without (RR: 0.71; 95% CI: 0.51-0.99, P=0.041) provisional or routine GPIs. Bivalirudin appeared to have a higher risk of stent thrombosis (RR: 1.32; 95% CI: 1.04-1.68, P=0.022) and a trend towards more myocardial infarction (RR: 1.12; 95% CI: 0.98-1.28, P=0.098) though without statistical significance. However, exclusion of studies with GPI showed no difference in stent thrombosis or myocardial infarction with bivalirudin. Conclusions Bivalirudin is associated with less major bleeding compared to heparin, regardless of GPI use. The lower anticoagulant effect of bivalirudin is linked with higher stent thrombosis and a trend towards more MI, however a confounding effect of GPI use in the heparin arm cannot be excluded.
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Affiliation(s)
- Mahesh Anantha-Narayanan
- Division of Cardiovascular Disease, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Dixitha Anugula
- Division of Cardiology, CHI Health Creighton University Medical Center, Omaha, NE, USA
| | - Nagarjuna R Gujjula
- Division of Cardiology, CHI Health Creighton University Medical Center, Omaha, NE, USA
| | - Yogesh N V Reddy
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Janani Baskaran
- Division of Cardiovascular Disease, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Manu Kaushik
- Division of Cardiovascular Diseases, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Venkata M Alla
- Division of Cardiology, CHI Health Creighton University Medical Center, Omaha, NE, USA
| | - Ganesh Raveendran
- Division of Cardiovascular Disease, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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9
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Mehrzad M, Tuktamyshov R, Mehrzad R. Safety, efficiency and cost effectiveness of Bivalirudin: A systematic review. World J Cardiol 2017; 9:761-772. [PMID: 29081910 PMCID: PMC5633541 DOI: 10.4330/wjc.v9.i9.761] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/31/2017] [Accepted: 08/16/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To review the early and more recent studies of Bivalirudin, to assess the safety, effectiveness, and cost benefits of this drug.
METHODS Literature search of MEDLINE and PubMed databases from 1990 to 2017 using keywords as “bivalirubin” and “angiomax”, combined with the words “safety”, “effectiveness”, “efficiency”, “side effects”, “toxicity”, “adverse effect”, and “adverse drug reaction”.
RESULTS A total of 66 publications were reviewed. The changes in clinical practice and differences in clinical protocols make it difficult to do direct comparisons of studies among each other. However, most trials showed decreased bleeding complications with bivalirudin, although ischemic complications and mortality were mostly comparable, with some favor towards bivalirudin.
CONCLUSION Bivalirudin and heparin are both acceptable options according to current ACA/AHA guidelines. Authors conclude however, that that due to bivalirudin safer bleeding profile, it should be the preferred medication for anticoagulation.
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Affiliation(s)
- Melorin Mehrzad
- Department of Internal Medicine, Yale New Haven Hospital, Yale School of medicine, New Haven, CT 06510, United States
| | - Rasikh Tuktamyshov
- Department of Internal Medicine, Yale New Haven Hospital, Yale School of medicine, New Haven, CT 06510, United States
| | - Raman Mehrzad
- Department of Internal Medicine, Yale New Haven Hospital, Yale School of medicine, New Haven, CT 06510, United States
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10
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Ahmad Hamdi AH, Dali AF, Mat Nuri TH, Saleh MS, Ajmi NN, Neoh CF, Ming LC, Abdullah AH, Khan TM. Safety and Effectiveness of Bivalirudin in Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis. Front Pharmacol 2017; 8:410. [PMID: 28744215 PMCID: PMC5504279 DOI: 10.3389/fphar.2017.00410] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 06/12/2017] [Indexed: 01/22/2023] Open
Abstract
Recent clinical trials have shown that while bivalirudin exhibits similar efficacy with heparin, it offers several advantages over heparin, such as a better safety profile. We aimed to evaluate the efficacy and safety of bivalirudin use during Percutaneous Coronary Intervention (PCI) in the treatment of angina and acute coronary syndrome (ACS). We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, EMBASE, and Science Direct from January 1980 to January 2016. Randomized controlled trials (RCTs) comparing bivalirudin to heparin during the course of PCI in patients with angina or ACS were included. Outcome measures included all-cause mortality, myocardial infarction, revascularisation, stent thrombosis, stroke, and major bleeding. The selection, quality assessment, and data extraction of the included trials were done independently by four authors, and disagreements were resolved by consensus. Pooled relative risk (RR) estimates and 95% confidence intervals (CIs) were calculated. A total of 12 RCTs involving 44,088 subjects were included. Bivalirudin appeared to be non-superior compared to heparin in reducing all-cause mortality, myocardial infarction, revascularisation, and stroke. Bivalirudin appeared to be related to a higher risk of stent thrombosis when compared to heparin plus provisional use of a glycoprotein IIb/IIIa inhibitor (GPI) at day 30 (RR 1.94 [1.16, 3.24] p < 0.01). Overall, bivalirudin-based regimens present a lesser risk of major bleeding (RR 0.56 [0.44–0.71] p < 0.001), and Thrombolysis In Myocardial Infarction (TIMI) major bleeding (RR 0.56 [0.43–0.73]) compared with heparin-based regimens either with provisional or routine use of a GPI. However, the magnitude of TIMI major bleeding effect varied greatly (p < 0.001), depending on whether a GPI was provisionally used (RR 0.42 [0.34–0.52] p < 0.001) or routinely used (RR 0.60 [0.43 –0.83] p < 0.001), in the heparin arm. This meta-analysis demonstrated that bivalirudin is associated with a lower risk of major bleeding, but a higher risk of stent thrombosis compared to heparin.
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Affiliation(s)
- Abdul Hafeez Ahmad Hamdi
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARAPuncak Alam, Malaysia
| | - Ahmad Fauzi Dali
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARAPuncak Alam, Malaysia
| | - Thimarul Huda Mat Nuri
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARAPuncak Alam, Malaysia
| | - Muhammad Syafiq Saleh
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARAPuncak Alam, Malaysia
| | - Noor Nabila Ajmi
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARAPuncak Alam, Malaysia
| | - Chin Fen Neoh
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARAPuncak Alam, Malaysia.,Collaborative Drug Discovery Research Group, Pharmaceutical and Life Sciences CoRe, Universiti Teknologi MARAShah Alam, Malaysia
| | - Long Chiau Ming
- Unit for Medication Outcomes Research and Education, Pharmacy, School of Medicine, University of TasmaniaHobart, TAS, Australia.,School of Pharmacy, KPJ Healthcare University CollegeNilai, Malaysia
| | - Amir Heberd Abdullah
- Vector-Borne Diseases Research Group (VERDI), Pharmaceutical and Life Sciences CoRe, Universiti Teknologi MARAShah Alam, Malaysia.,Faculty of Health Sciences, Universiti Teknologi MARABertam, Malaysia
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11
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Zhang S, Gao W, Li H, Zou M, Sun S, Ba Y, Liu Y, Cheng G. Efficacy and safety of bivalirudin versus heparin in patients undergoing percutaneous coronary intervention: A meta-analysis of randomized controlled trials. Int J Cardiol 2016; 209:87-95. [DOI: 10.1016/j.ijcard.2016.01.206] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 01/15/2016] [Accepted: 01/22/2016] [Indexed: 10/22/2022]
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12
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13
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Bittl JA, He Y, Lang CD, Dangas GD. Factors Affecting Bleeding and Stent Thrombosis in Clinical Trials Comparing Bivalirudin With Heparin During Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2015; 8:e002789. [DOI: 10.1161/circinterventions.115.002789] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John A. Bittl
- From the Cardiac Catherization Laboratory, Munroe Regional Medical Center, Ocala, FL (J.A.B.); Office of Research and Methodology, National Center for Health Statistics, Hyattsville, MD (Y.H.); Division of Cardiology, Eastern Maine Medical Center, Bangor, ME (C.D.L.); and Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.D.D.)
| | - Yulei He
- From the Cardiac Catherization Laboratory, Munroe Regional Medical Center, Ocala, FL (J.A.B.); Office of Research and Methodology, National Center for Health Statistics, Hyattsville, MD (Y.H.); Division of Cardiology, Eastern Maine Medical Center, Bangor, ME (C.D.L.); and Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.D.D.)
| | - Christopher D. Lang
- From the Cardiac Catherization Laboratory, Munroe Regional Medical Center, Ocala, FL (J.A.B.); Office of Research and Methodology, National Center for Health Statistics, Hyattsville, MD (Y.H.); Division of Cardiology, Eastern Maine Medical Center, Bangor, ME (C.D.L.); and Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.D.D.)
| | - George D. Dangas
- From the Cardiac Catherization Laboratory, Munroe Regional Medical Center, Ocala, FL (J.A.B.); Office of Research and Methodology, National Center for Health Statistics, Hyattsville, MD (Y.H.); Division of Cardiology, Eastern Maine Medical Center, Bangor, ME (C.D.L.); and Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.D.D.)
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14
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Kianoush S, Bikdeli B, Desai MM, Eikelboom JW. Risk of Stent Thrombosis and Major Bleeding with Bivalirudin Compared with Active Control: A Systematic Review and Meta-analysis of Randomized Trials. Thromb Res 2015; 136:1087-98. [DOI: 10.1016/j.thromres.2015.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/23/2015] [Accepted: 06/01/2015] [Indexed: 11/26/2022]
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15
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Farag M, Gorog DA, Prasad A, Srinivasan M. Bivalirudin versus unfractionated heparin: a meta-analysis of patients receiving percutaneous coronary intervention for acute coronary syndromes. Open Heart 2015; 2:e000258. [PMID: 26448869 PMCID: PMC4593234 DOI: 10.1136/openhrt-2015-000258] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 08/07/2015] [Accepted: 08/27/2015] [Indexed: 11/16/2022] Open
Abstract
Objective Acute coronary syndrome (ACS) encompasses ST segment elevation myocardial infarction (STEMI), with generally high thrombus burden and non-ST segment elevation ACS (NSTE-ACS), with lower thrombus burden. In the setting of percutaneous coronary intervention (PCI) for ACS, bivalirudin appears superior to unfractionated heparin (UFH), driven by reduced major bleeding. Recent trials suggest that the benefit of bivalirudin may be reduced with use of transradial access and evolution in antiplatelet therapy. Moreover, a differential role of bivalirudin in ACS cohorts is unknown. Methods A meta-analysis of randomised trials comparing bivalirudin and UFH in patients with ACS receiving PCI, with separate analyses in STEMI and NSTE-ACS groups. Overall estimates of treatment effect were calculated with random-effects model. Results In 5 trials of STEMI (10 358 patients), bivalirudin increased the risk of acute stent thrombosis (ST) (OR 3.62; CI 1.95 to 6.74; p<0.0001) compared with UFH. Bivalirudin reduced the risk of major bleeding only when compared with UFH plus planned glycoprotein IIb/IIIa inhibitors (GPI) (OR 0.49; CI 0.36 to 0.67; p<0.00001). In 14 NSTE-ACS trials (25 238 patients), there was no difference between bivalirudin and UFH in death, myocardial infarction or ST. However, bivalirudin reduced the risk of major bleeding compared with UFH plus planned GPI (OR 0.52; CI 0.43 to 0.62; p<0.00001), or UFH plus provisional GPI (OR 0.68; CI 0.46 to 1.01; p=0.05). The reduction in major bleeding with bivalirudin was not related to vascular access site. Conclusions Bivalirudin increases the risk of acute ST in STEMI, but may confer an advantage over UFH in NSTE-ACS while undergoing PCI, reducing major bleeding without an increase in ST.
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Affiliation(s)
- Mohamed Farag
- Department of Cardiology , East and North Hertfordshire NHS Trust , Hertfordshire , UK ; Postgraduate Medical School, University of Hertfordshire , Hertfordshire , UK
| | - Diana A Gorog
- Department of Cardiology , East and North Hertfordshire NHS Trust , Hertfordshire , UK ; Postgraduate Medical School, University of Hertfordshire , Hertfordshire , UK ; National Heart & Lung Institute, Imperial College , London , UK
| | - Abhiram Prasad
- Cardiovascular and Cell Sciences Research Institute, St George's, University of London , London , UK
| | - Manivannan Srinivasan
- Department of Cardiology , East and North Hertfordshire NHS Trust , Hertfordshire , UK
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16
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Li J, Yu S, Qian D, He Y, Jin J. Bivalirudin Anticoagulant Therapy With or Without Platelet Glycoprotein IIb/IIIa Inhibitors During Transcatheter Coronary Interventional Procedures: A Meta-Analysis. Medicine (Baltimore) 2015; 94:e1067. [PMID: 26266343 PMCID: PMC4616679 DOI: 10.1097/md.0000000000001067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The safety and effectiveness of using the direct thrombin inhibitor bivalirudin during transcatheter coronary interventional procedures remains uncertain.This study aimed to systematically assess anticoagulation with bivalirudin alone or bivalirudin plus glycoprotein (GP) IIb/IIIa inhibitors (bivalirudin-based anticoagulant therapy) in patients undergoing percutaneous coronary intervention (PCI) procedures by a meta-analysis of randomized controlled trials (RCTs).Systematical searches of the MEDLINE, EMBASE, and Cochrane databases were conducted. RCTs comparing bivalirudin-based anticoagulant therapy with a comparable heparin therapy in patients undergoing PCI were eligible. Risk ratios (RRs) with 95% confidence intervals (CIs) served as summary statistics.A total of 38,096 patients from 17 RCTs were randomized to the bivalirudin group (n = 18,878) or heparin group (n = 19,218) in the meta-analysis. No significant differences in death, myocardial infarction or reinfarction, ischemia-driven revascularization, or in-stent thrombosis were observed between the 2 groups (all P > 0.05). Notably, bivalirudin-based therapy showed a highly significant 34% decrease in the incidence of major bleeding (RR = 0.66; 95% CI 0.54-0.81; P < 0.001) and a 28% reduction in the need for blood transfusion (RR = 0.72; 95% CI 0.56-0.91; P < 0.01). Meta-regression analyses demonstrated that additional administration of GP IIb/IIIa receptor inhibitors (P = 0.01), especially eptifibatide (P = 0.001) and tirofiban (P = 0.002), was likely to increase the major bleeding risk associated with bivalirudin.Bivalirudin, in comparison to heparin, is associated with a markedly lower risk of major bleeding, and the additional use of GP IIb/IIIa inhibitors may weaken this benefit.
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Affiliation(s)
- Jiabei Li
- From the Institute of Cardiovascular Science, Xinqiao Hospital, Third Military Medical University, Chongqing, China
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17
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Bivalirudin Versus Heparin Plus Glycoprotein IIb/IIIa Inhibitors in Patients with Diabetes Mellitus Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials. Am J Cardiovasc Drugs 2015; 15:275-85. [PMID: 25782437 DOI: 10.1007/s40256-015-0113-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Diabetes mellitus (DM) is a pro-thrombotic state with enhanced thrombin generation and platelet reactivity. For most patients undergoing percutaneous coronary intervention (PCI), bivalirudin demonstrates efficacy comparable with that of heparin and glycoprotein IIb/IIIa inhibitors (GPIs). Yet, because of their pro-thrombotic condition, we hypothesized that patients with DM may benefit from more aggressive dual antithrombin and antiplatelet therapy. The aim of this paper was to provide a systematic review comparing outcomes of PCI with bivalirudin versus heparin plus GPI in patients with DM using meta-analytical techniques. Eligible studies needed to have reported a subgroup analysis of outcomes among diabetic patients. Six trials comprising 5924 diabetic patients were eligible. At 30 days, bivalirudin was associated with a reduction in net adverse cardiac events [relative risk (RR) 0.81, 95 % confidence interval (CI) 0.70-0.93, p = 0.002] and major bleeds (RR 0.68, 95 % CI 0.49-0.95; p = 0.02), with no difference in composite ischemia (RR 0.92, 95 % CI 0.74-1.14; p = 0.43) or mortality (RR 0.71, 95 % CI 0.45-1.13; p = 0.15). At 1 year, bivalirudin was associated with a significant reduction in all-cause mortality (RR 0.73, 95 % CI 0.54-1.00, p = 0.05) despite similar composite ischemia (RR 1.02, 95 % CI 0.56-1.21, p = 0.811). In conclusion, thrombin inhibition with bivalirudin alone was associated with reduced 30-day major bleeding and 1-year all-cause mortality compared with heparin plus GPI in diabetic patients undergoing PCI.
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Centurión OA. Heparin Versus Bivalirudin in Contemporary Percutaneous Coronary Intervention: A Welcome Back to an Old Friend Unfractionated Heparin. Crit Pathw Cardiol 2015; 14:62-66. [PMID: 26102015 DOI: 10.1097/hpc.0000000000000043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The results of randomized trials and observational studies make a strong argument for the use of bivalirudin rather than heparin plus systematic glycoprotein (GP) IIb/IIIa inhibitors for the great majority of patients undergoing percutaneous coronary interventions (PCI). However, there is no doubt that the benefit observed with bivalirudin was achieved because of the major bleeding complications with heparin plus GP IIb/IIIa inhibitors. Therefore, if we diminish bleeding complications by eliminating the systematic utilization of GP IIb/IIIa inhibitors, there would be a lesser benefit with the use of bivalirudin. When this latter drug was compared with unfractionated heparin alone there was no benefit in ischemic complications but a decrease in major bleeding complications with bivalirudin. However, a very recent meta-analysis shed more insights on the utilization of bivalirudin versus heparin regimens during PCI. Findings from this meta-analysis suggest that routine use of bivalirudin offers little advantage over heparin among PCI patients. In a detailed analysis of some randomized trials and observational studies with bivalirudin in non-ST-segment elevation acute coronary syndrome patients done by myself and published almost 4 years ago in this journal, I rendered some reflections on the future widespread use of bivalirudin. "In the setting of PCI and in the absence of GP IIb/IIIa inhibitors, bivalirudin did not offer any beneficial effect in the incidence of the composite end points when compared with heparin. For now, in real world practice, one would probably choose a well-known cheaper drug that has already passed the test of time, heparin. There may be reinforcement in the sole utilization of heparin confining GP IIb/IIIa inhibitors and other intravenous antithrombotics to bailout therapy for periprocedural PCI complications in acute coronary syndrome patients." Therefore, is it the beginning of a new era with bivalirudin or is it a welcome back to an old friend, heparin? Indeed, after more than two decades, it is always good to welcome back an old friend, unfractionated heparin.
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Affiliation(s)
- Osmar Antonio Centurión
- From the Department of Cardiology, Clínic Hospital, Asunción National University, Asunción, Paraguay; and Cardiovascular Institute, Sanatorio Migone-Battilana, Asunción, Paraguay
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Bavry AA, Elgendy IY, Mahmoud A, Jadhav MP, Huo T. Critical Appraisal of Bivalirudin versus Heparin for Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Trials. PLoS One 2015; 10:e0127832. [PMID: 26010682 PMCID: PMC4444249 DOI: 10.1371/journal.pone.0127832] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 04/20/2015] [Indexed: 12/28/2022] Open
Abstract
Percutaneous coronary intervention with bivalirudin plus bail-out glycoprotein IIb/IIIa inhibitors has been shown to be as effective as unfractionated heparin plus routine glycoprotein IIb/IIIa inhibitors in preventing cardiac ischemic events, but with a lower bleeding risk. It is unknown whether bivalirudin would have the same beneficial effects if compared with heparin when the use of glycoprotein IIb/IIIa inhibitors was similar between treatment arms. We searched the MEDLINE, Web of Science, and Cochrane databases from inception until March 2015 for randomized trials that compared bivalirudin to heparin in patients undergoing percutaneous coronary intervention. We required that the intended use of glycoprotein IIb/IIIa inhibitors was similar between the study groups. Summary estimates were principally constructed by the Peto method. Fifteen trials met our inclusion criteria, which yielded 25,824 patients. Bivalirudin versus heparin was associated with an increased hazard of stent thrombosis (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.15-1.92, P = .002, I2 = 16.9%), with a similar hazard of myocardial infarction (OR 1.09, 95% CI 0.98-1.22, P = .11, I2 = 35.8%), all-cause mortality (OR 0.88, 95% CI 0.72-1.08, P = .21, I2 = 31.5%) and major adverse cardiac events (OR 1.04, 95% CI 0.94-1.14, P = .46, I2 = 53.9%). Bivalirudin was associated with a reduced hazard of major bleeding (OR 0.80, 95% CI 0.70-0.92, P = .001, I2 = 63.5%). The dose of heparin in the control arm modified this association; when the dose of unfractionated heparin in the control arm was ≥ 100 units/kg, bivalirudin was associated with a reduction in major bleeding (OR 0.55, 95% CI 0.45-0.68, P < .0001), but when the dose of unfractionated heparin was ≤ 75 units/kg, bivalirudin was not associated with reduction in bleeding (OR 1.09, 95% CI 0.91-1.31, P = .36). Among patients undergoing PCI, bivalirudin was associated with an increased hazard of stent thrombosis. Bivalirudin may be associated with a reduced hazard of major bleeding; however, this benefit was no longer apparent when compared with a dose of unfractionated heparin ≤ 75 units/kg.
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Affiliation(s)
- Anthony A. Bavry
- North Florida/South Georgia Veterans Health System, Gainesville, Florida, United States of America
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
| | - Islam Y. Elgendy
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Ahmed Mahmoud
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Manoj P. Jadhav
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Tianyao Huo
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
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Nairooz R, Sardar P, Amin H, Chatterjee S, Helmy T, Naidu SS. Short- and long-term outcomes in diabetes patients undergoing percutaneous coronary intervention with bivalirudin compared with heparin and glycoprotein IIb/IIIA inhibitors: A meta-analysis of randomized trials. Catheter Cardiovasc Interv 2015; 86:364-75. [PMID: 25914388 DOI: 10.1002/ccd.25952] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 03/15/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Diabetes patients undergoing percutaneous coronary intervention (PCI) have more complications than nondiabetes patients, including increased long-term mortality. Use of bivalirudin versus heparin and glycoprotein IIb/IIIa inhibitors (GPI) in diabetes patients undergoing PCI and its effect on long-term mortality were evaluated in few randomized trials, but with conflicting results. METHODS We searched the literature for randomized controlled trials that compared heparin and GPI therapy with bivalirudin in diabetes patients undergoing PCI. The incidence of major adverse cardiovascular events (MACE), death from any cause, myocardial infarction (MI), urgent revascularization, major and minor bleeding (at 30 days), as well as all-cause mortality at 1 year were included, and meta-analysis was performed. RESULTS A total of 5,137 patients with diabetes were included in four randomized trials. At 30 days, bivalirudin, compared with heparin and GPI, caused less major bleeding (odds ratio (OR), 0.68; 95% confidence interval (CI), 0.52-0.89; P = 0.005) and less minor bleeding (OR, 0.48; 95% CI, 0.41-0.57; P < 0.00001) and similar rates of MACE (OR, 0.87; 95% CI, 0.70-1.08; P = 0.21), MI (OR, 0.87; 95% CI, 0.68-1.10; P = 0.25), and urgent revascularization (OR, 1.12; 95% CI, 0.76-1.65; P = 0.57). Death from any cause at 30 day was numerically lower with bivalirudin use but not statistically significant (OR, 0.72; 95% CI, 0.46-1.13; P = 0.15). Mortality at 1 year was significantly lower in diabetes patients treated with bivalirudin compared with heparin and GPI (OR, 0.72; 95% CI, 0.52-0.99; P = 0.04). A secondary analysis suggests that the major bleeding benefit with bivalirudin may be driven by mandated use of GPI in heparin arm. CONCLUSION Among patients with diabetes undergoing PCI, bivalirudin caused less major and minor bleeding compared with heparin and GPI, with similar rates of MACE, death, MI, and urgent revascularization at 30 days, but significantly lower mortality rates at 1 year.
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Affiliation(s)
- Ramez Nairooz
- Department of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Partha Sardar
- Department of Cardiology, University of Utah, Salt Lake City, Utah
| | - Hossam Amin
- Department of Medicine, New York Medical College-Metropolitan Hospital Center, New York City, New York
| | - Saurav Chatterjee
- Department of Cardiology, St. Luke's-Roosevelt Hospital Center of the Mount Sinai Health System, New York City, New York
| | - Tarek Helmy
- Department of Cardiology, University of Cincinnati, Cincinnati, Ohio
| | - Srihari S Naidu
- Department of Cardiology, Winthrop University Hospital, Mineola, New York
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21
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Mavrakanas TA, Chatzizisis YS. Bivalirudin in stable angina and acute coronary syndromes. Pharmacol Ther 2015; 152:1-10. [PMID: 25857452 DOI: 10.1016/j.pharmthera.2015.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 03/31/2015] [Indexed: 01/05/2023]
Abstract
A parenteral anticoagulant is indicated in patients with acute coronary syndromes. Which anticoagulant should be preferred in each setting is not clearly established. Bivalirudin administration was considered in acute coronary syndromes after several clinical trials showed decreased bleeding risk with its use compared with the association of unfractionated heparin (UFH) with glycoprotein IIb/IIIa inhibitors (GPIs). Most recent data demonstrate that the bleeding benefit identified in the previous studies was not due to bivalirudin's properties but to higher bleeding incidence in the comparator arm due to the disproportional use of GPIs with heparin. This paper reviews clinical evidence on bivalirudin as anticoagulant in stable angina and acute coronary syndromes.
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Affiliation(s)
- Thomas A Mavrakanas
- McGill University Health Center, Montreal, Canada; General Internal Medicine Division, Geneva University Hospitals, Geneva, Switzerland
| | - Yiannis S Chatzizisis
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.
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22
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Verdoia M, Schaffer A, Barbieri L, Suryapranata H, De Luca G. Bivalirudin as compared to unfractionated heparin in patients undergoing percutaneous coronary revascularization: A meta-analysis of 22 randomized trials. Thromb Res 2015; 135:902-15. [PMID: 25772138 DOI: 10.1016/j.thromres.2015.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 01/19/2015] [Accepted: 03/03/2015] [Indexed: 12/28/2022]
Abstract
UNLABELLED Bivalirudin has gained ground against unfractionated heparin (UFH) in percutaneous coronary interventions (PCI), due to a reported better safety profile. However, whether bivalirudin may provide also advantages in clinical outcome beyond the known benefits in major bleedings, is still a debated matter and was, therefore, the aim of present meta-analysis of randomized trials, evaluating efficacy and safety of bivalirudin as compared with UFH in PCI. METHODS AND STUDY OUTCOMES Literature archives (Pubmed, EMBASE, Cochrane) and main scientific sessions were scanned. Primary endpoint was overall mortality. Secondary endpoints were: 1) mortality within 30-days; 2) overall and within 30-days non fatal myocardial infarction; 3) overall and within 30-days stent thrombosis. Safety endpoints were major bleedings (per protocol definition or TIMI classification). A prespecified analysis was conducted according to clinical presentation (Elective, ACS, STEMI). RESULTS A total of 22 randomized clinical were finally included, involving 40156 patients randomized to bivalirudin (52.9%) or to UFH (47.1%). Death occurred in 1100 (2.8%) of patients, with no difference between bivalirudin and UFH (2.7% vs 2.8% OR[95%C]=0.94[0.83,-.06], p=0.32, phet=0.48). The results did not change according to clinical presentation. By meta-regression analysis, the effects on mortality were not related to patients risk profile (r=-0.38(-0.89-0.14), p=0.15) or the reduction in bleeding complications (r=-0.008(-0.86-0.85), p=0.98). A significant increase in short-term stent thrombosis was observed with bivalirudin (OR[95%CI]=1.42 [1.10-1.83], p=0.006). However, Bivalirudin significantly reduced bleedings according to both study protocol definition (OR[95%CI]=0.62[0.56-0.69],p<0.00001; phet=0.0003) or TIMI major criteria (OR[95%CI]=0.65[0.53-0.79],p<0.0001, phet=0.95). CONCLUSIONS In present meta-analysis, among patients undergoing PCI, bivalirudin, as compared with UFH, is associated with a significant reduction in major bleeding complications that, however, does not translate into mortality benefits. Furthermore, bivalirudin is associated with higher rate of 30-days stent thrombosis and recurrent MI among STEMI patients.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Alon Schaffer
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Lucia Barbieri
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | | | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
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Piccolo R, De Biase C, D'Anna C, Trimarco B, Piscione F, Galasso G. Early stent thrombosis with bivalirudin in patients undergoing percutaneous coronary intervention. A meta-analysis of randomised clinical trials. Thromb Haemost 2015; 113:1010-20. [PMID: 25673109 DOI: 10.1160/th14-08-0646] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 12/31/2014] [Indexed: 01/27/2023]
Abstract
Although bivalirudin has been shown to reduce bleeding events in patients undergoing percutaneous coronary intervention, residual concerns remain about a possible higher risk of early (within 30 days) stent thrombosis (ST). Therefore, we performed a meta-analysis of randomised trials reporting ST events with bivalirudin compared to other antithrombotic therapies (heparins ± glycoprotein IIb/IIIa inhibitors). A systematic literature search of electronic resources was performed through May, 2014. The primary endpoint was definite early ST, according to Academic Research Consortium criteria. Secondary endpoints included: all-cause death, myocardial infarction and major bleeding. A total of 11 trials, including 16,415 patients, were accrued. Compared to other regimens, bivalirudin significantly increased the risk of early ST (odds ratio [OR]=1.80; 95 % confidence interval [CI], 1.28-2.52; p=0.0007) and reduced the risk of major bleeding (OR [95 %CI]=0.64 [0.51-0.82], p=0.0003), with a comparable risk of mortality or myocardial infarction. The higher risk of early ST was mainly attributable to acute (OR [95 % CI] =4.33 [2.33-8.05], p < 0.001) than subacute (OR [95 % CI] =0.89 [0.53-1.50], p =0.67) ST events (p for interaction < 0.001). Non-fatal myocardial infarction was the most common presentation (83 %) of early ST events, while death occurred infrequently (about 5 %). In conclusion, in patients undergoing PCI, bivalirudin compared to heparins is associated with a higher risk of early ST, which is mainly related to more frequent acute events. Further studies are required to evaluate alternative strategies to mitigate this risk, without hampering the benefits derived from the reduction in bleeding events with bivalirudin.
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Affiliation(s)
| | | | | | | | | | - Gennaro Galasso
- Gennaro Galasso, MD, PhD, Department of Advanced Biomedical Sciences, Via S. Pansini, 5. 80131. Naples, Italy, Tel.: +390817462234, Fax: +390817462229, E-mail:
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24
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Huang FY, Huang BT, Peng Y, Liu W, Zhao ZG, Wang PJ, Zuo ZL, Zhang C, Liao YB, Luo XL, Meng QT, Chen C, Huang KS, Chai H, Li Q, Chen M, Zhu Y. Heparin is Not Inferior to Bivalirudin in Percutaneous Coronary Intervention-Focusing on the Effect of Glycoprotein IIb/IIIa Inhibitor Use: A Meta-Analysis. Angiology 2015; 66:845-55. [PMID: 25635117 DOI: 10.1177/0003319715568972] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Our aim was to compare the efficacy and safety of bivalirudin (Biv) versus heparin (Hep) with or without similar usage rate of glycoprotein IIb/IIIa inhibitors (GPIs) during percutaneous coronary intervention (PCI). The PubMed and EMbase were searched. Randomized trials comparing Biv versus Hep were eligible for inclusion. With imbalanced GPI use, Biv had significantly lower major bleeding (pooled risk ratio [RR], 0.67; 95% confidence interval [CI], 0.54-0.83) without difference in mortality (pooled RR, 0.95; 95% CI, 0.80-1.14). With comparable GPI use, no significant difference was observed in major bleeding (pooled RR, 0.95; 95% CI, 0.82-1.10) and mortality (pooled RR, 1.13; 95% CI, 0.85-1.50). With no GPI use, Biv was associated with numerically higher mortality (pooled RR, 1.17; 95% CI, 0.83-1.65) without significant difference in major bleeding (pooled RR, 0.81; 95% CI, 0.64-1.02). In conclusion, when comparing different anticoagulants during PCI, the effect of GPIs should not be underestimated. Heparin as such was found noninferior to Biv.
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Affiliation(s)
- Fang-Yang Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Bao-Tao Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Liu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhen-Gang Zhao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Peng-Ju Wang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhi-Liang Zuo
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Chen Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yan-Biao Liao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiao-Lin Luo
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Qing-Tao Meng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Chi Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Kai-Sen Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hua Chai
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Qiao Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ye Zhu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
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Lipinski MJ, Lhermusier T, Escarcega RO, Baker NC, Magalhães MA, Torguson R, Suddath WO, Satler LF, Pichard AD, Waksman R. Bivalirudin versus heparin for percutaneous coronary intervention: an updated meta-analysis of randomized controlled trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2014; 15:315-22. [DOI: 10.1016/j.carrev.2014.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 08/29/2014] [Indexed: 11/29/2022]
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Cavender MA, Sabatine MS. Bivalirudin versus heparin in patients planned for percutaneous coronary intervention: a meta-analysis of randomised controlled trials. Lancet 2014; 384:599-606. [PMID: 25131979 DOI: 10.1016/s0140-6736(14)61216-2] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Bivalirudin is an alternative to heparin in patients undergoing percutaneous coronary intervention (PCI). We aimed to define the effects of a bivalirudin-based anticoagulation regimen compared with a heparin-based anticoagulation regimen on ischaemic and bleeding outcomes. METHODS We searched Medline, the Cochrane Library, and relevant meeting abstracts (search done on April 9, 2014) for randomised trials that assessed bivalirudin versus heparin in patients planned for PCI. The primary efficacy endpoint was the incidence of major adverse cardiac events (MACE) up to 30 days. Secondary efficacy endpoints were death, myocardial infarction, ischaemia-driven revascularisation, and stent thrombosis. The primary safety endpoint was major bleeding up to 30 days. We calculated pooled risk ratios and 95% CIs using random-effects models. FINDINGS We included data from 16 trials involving 33 958 patients, of whom 2422 experienced MACE and 1406 had a major bleed. There was an increase in the risk of MACE with bivalirudin-based regimens compared with heparin-based regimens (risk ratio 1·09, 95% CI 1·01-1·17; p=0·0204), which was largely driven by increases in myocardial infarction (1·12, 1·03-1·23) and seemingly also by ischaemia-driven revascularisation (1·16, 0·997-1·34) with bivalirudin compared with heparin, with no effect on mortality (0·99, 0·82-1·18). Bivalirudin increased the risk of stent thrombosis (risk ratio 1·38, 95% CI 1·09-1·74; p=0·0074), which was primarily due to an increase in acute cases in ST-segment elevation myocardial infarction (4·27, 2·28-8·00; p<0·0001). Overall, bivalirudin-based regimens lowered the risk of major bleeding (risk ratio 0·62, 95% CI 0·49-0·78; p<0·0001), but the magnitude of this effect varied greatly (p<0·0001) depending on whether glycoprotein IIb/IIIa inhibitors were used predominantly in the heparin arm only (0·53, 0·47-0·61; p<0·0001), provisionally in both arms (0·78, 0·51-1·19; p=0·25), or planned in both arms (1·07, 0·87-1·31; p=0·53). INTERPRETATION Compared with a heparin-based regimen, a bivalirudin-based regimen increases the risk of myocardial infarction and stent thrombosis, but decreases the risk of bleeding, with the magnitude of the reduction depending on concomitant glycoprotein IIb/IIIa inhibitor use. Physicians should weigh the trade-off between ischaemic and bleeding events when choosing between different anticoagulant regimens. FUNDING None.
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Affiliation(s)
- Matthew A Cavender
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Tarantini G, Brener SJ, Barioli A, Gratta A, Parodi G, Rossini R, Navarese EP, Niccoli G, Frigo AC, Musumeci G, Iliceto S, Stone GW. Impact of baseline hemorrhagic risk on the benefit of bivalirudin versus unfractionated heparin in patients treated with coronary angioplasty: a meta-regression analysis of randomized trials. Am Heart J 2014; 167:401-412.e6. [PMID: 24576526 DOI: 10.1016/j.ahj.2013.11.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 11/24/2013] [Indexed: 01/26/2023]
Abstract
BACKGROUND Bivalirudin significantly reduces 30-day major and minor bleeding compared with unfractionated heparin (UFH), while resulting in similar or lower rates of ischemic events in both patients with stable and unstable coronary disease undergoing percutaneous coronary intervention. We performed a meta-analysis of randomized trials to evaluate the impact of bivalirudin compared with UFH, with or without glycoprotein IIb/IIIa receptor inhibitors (GPI), on the rates of mortality, myocardial infarction (MI), and major bleeding. METHODS We searched electronic databases for randomized controlled trials with >100 patients comparing bivalirudin (±provisional GPI) with UFH with either routine or provisional GPI in patients undergoing percutaneous coronary intervention. The principal efficacy end points were mortality and MI within 30 day, whereas major bleeding was the principal safety end point. We assessed the benefit of bivalirudin for each efficacy end point relative to the baseline bleeding risk, using the control (UFH) major bleeding rate as proxy for that risk. RESULTS A total of 12 randomized trials that enrolled 33,261 patients were included. Overall, there was no significant difference in mortality and MI between bivalirudin monotherapy and UFH (±GPI), whereas major bleeding was significantly lower with bivalirudin. Bivalirudin reduced major and minor bleeding across the entire bleeding risk spectrum. CONCLUSIONS Bivalirudin significantly reduces major and minor bleeding regardless of the estimated baseline hemorrhagic risk.
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Van De Car DA, Rao SV, Ohman EM. Bivalirudin: a review of the pharmacology and clinical application. Expert Rev Cardiovasc Ther 2014; 8:1673-81. [DOI: 10.1586/erc.10.158] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Berger PB, Williams JB, Hasselblad V, Chiswell K, Pieper KS, Califf RM. Would tirofiban have been shown non-inferior to abciximab had the TENACITY trial not been terminated for financial reasons? J Interv Cardiol 2013; 26:123-30. [PMID: 23379785 DOI: 10.1111/j.1540-8183.2013.12020.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To investigate whether tirofiban would have been non-inferior to abciximab had the trial completed enrollment and place the termination of this trial in a broader research ethics context. BACKGROUND TENACITY was terminated by the sponsor for financial reasons. At the time, event rates for the 2 treatment arms were unknown. METHODS TENACITY was designed to compare tirofiban with abciximab in approximately 8,000 patients; however, enrollment was terminated after 383 (4.8%) patients. The primary end-point was a composite of 30-day death, myocardial infarction, and urgent target vessel revascularization. Non-inferiority was defined as the likelihood that tirofiban would preserve at least 50% of the ability of abciximab to reduce the primary end-point at 30 days, based on abciximab's demonstrated ability to reduce such events by 43% (relative risk, 0.573; 95% confidence interval [CI], 0.507-0.648; P < 0.001). To determine the probability of non-inferiority given the patients already enrolled, a Bayesian approach was used. RESULTS The primary composite end-point occurred in 8.8% of patients randomized to abciximab versus 6.9% receiving high-bolus-dose tirofiban (odds ratio, 0.77; 95% CI, 0.37-1.64). The estimated conditional power for the test that tirofiban would be non-inferior to abciximab if all patients been enrolled is 93.7%. Using the estimated predictive power method, the likelihood was 84.8%. CONCLUSIONS TENACITY was well powered to identify non-inferiority with tirofiban versus abciximab, and the patients enrolled strengthened the probability that this would have been the outcome had the trial been completed. When a clinical trial is terminated solely for financial reasons, it is incumbent upon the sponsor to provide proper patient follow-up and publication of the findings.
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Patti G, Pasceri V, D'Antonio L, D'Ambrosio A, Macrì M, Dicuonzo G, Colonna G, Montinaro A, Di Sciascio G. Comparison of safety and efficacy of bivalirudin versus unfractionated heparin in high-risk patients undergoing percutaneous coronary intervention (from the Anti-Thrombotic Strategy for Reduction of Myocardial Damage During Angioplasty-Bivalirudin vs Heparin study). Am J Cardiol 2012; 110:478-84. [PMID: 22583760 DOI: 10.1016/j.amjcard.2012.04.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 04/08/2012] [Accepted: 04/08/2012] [Indexed: 12/21/2022]
Abstract
Bivalirudin, a direct thrombin inhibitor, is as effective as unfractionated heparin (UFH), with decreased bleeding in patients with acute coronary syndromes who undergo percutaneous coronary intervention (PCI). The aim of this study was to evaluate the effectiveness of bivalirudin versus UFH in selected PCI patients at high bleeding risk. Four hundred one consecutive patients who underwent PCI fulfilling ≥ 1 enrollment criterion (age >75 years, chronic renal failure, and diabetes mellitus) were randomized to bivalirudin (bolus 0.75 mg/kg followed by infusion during the procedure; n = 198) or UFH (75 IU/kg; n = 203). In the overall population, 39% were aged >75 years, 22% had renal failure, 63% had diabetes, and 29% had acute coronary syndromes. The primary efficacy end point was the 30-day incidence of major adverse cardiac events (cardiac death, myocardial infarction, stent thrombosis, or target vessel revascularization). The primary safety end point was the occurrence of any bleeding or entry-site complications after PCI. All patients were preloaded with clopidogrel 600 mg. Glycoprotein IIb/IIIa inhibitors were used at the operators' discretion. Thirty-day major adverse cardiac event rates were 11.1% in the bivalirudin group and 8.9% in the UFH group (p = 0.56); the primary efficacy end point was reached mainly because of periprocedural myocardial infarction; 1 patient in the bivalirudin group had stent thrombosis. Occurrence of the primary safety end point was 1.5% in the bivalirudin group and 9.9% in the UFH group (p = 0.0001); this benefit was essentially driven by the prevention of entry-site hematomas >10 cm (0.5% vs 6.9%, p = 0.002). In conclusion, Anti-Thrombotic Strategy for Reduction of Myocardial Damage During Angioplasty-Bivalirudin vs Heparin (ARMYDA-7 BIVALVE) indicates that bivalirudin, compared with UFH, causes significantly lower bleeding and has a similar incidence of major adverse cardiac events in patients with older age, diabetes mellitus, or chronic renal failure who undergo PCI.
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Abstract
Limitations of commonly used anticoagulants, unfractionated heparin, low-molecular-weight heparin, and oral vitamin K antagonists have prompted the development of alternative therapies. Direct thrombin inhibitors are a new class of anticoagulants that bind directly to thrombin and inhibit its interaction with substrates. In this Review, we critically examine the evidence from randomized controlled trials for the efficacy and safety of the parenteral direct thrombin inhibitors bivalirudin and argatroban, and the novel oral direct thrombin inhibitor dabigatran etexilate, in cardiovascular and thrombotic disease.
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Thompson KA, Philip KJ, Schwarz ER. Clinical Applications of Bivalirudin in the Cardiac Catheterization Laboratory. J Cardiovasc Pharmacol Ther 2010; 16:140-9. [DOI: 10.1177/1074248410385682] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Heparin has been used in the catheterization laboratory to prevent ischemic complications of percutaneous coronary intervention (PCI). Bivalirudin, a direct thrombin inhibitor, is an anticoagulant that has several pharmacologic advantages over heparin, and it has been proposed that bivalirudin is superior to heparin in its ability to prevent bleeding complications of PCI. As such, there have been a variety of large prospective clinical trials comparing bivalirudin and heparin over the past 13 years. The results of these trials have prompted the general acceptance of bivalirudin as a safe alternative to heparin use during PCI, and bivalirudin has been given a class 1 recommendation by the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for a variety of clinical indications. This article will review the data supporting the use of bivalirudin in the cardiac catheterization laboratory and describe several advantages of bivalirudin over traditional heparin use. We also include a discussion of the use of bivalirudin in conjunction with other medications that are frequently used in the catheterization laboratory. We end with an analysis of the economic differences between bivalirudin and heparin and the impact that financial factors may have on the choice of anticoagulant.
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Affiliation(s)
- Keith A. Thompson
- Division of Cardiology, Department of Medicine, Cedars Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Kiran J. Philip
- Division of Cardiology, Department of Medicine, Cedars Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Ernst R. Schwarz
- Division of Cardiology, Department of Medicine, Cedars Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA,
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Ferreiro JL, Cequier ÁR, Angiolillo DJ. Antithrombotic therapy in patients with diabetes mellitus and coronary artery disease. Diab Vasc Dis Res 2010; 7:274-88. [PMID: 20921091 DOI: 10.1177/1479164110383995] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Currently approved antiplatelet treatment strategies have proved successful for reducing cardiovascular adverse events in patients with CAD. However, despite the use of recommended antiplatelet treatment strategies, the presence of DM has been consistently associated with a negative impact on outcomes and a high rate of adverse cardiovascular events continue to occur in patients with DM. The elevated prevalence of low response to standard oral antiplatelet agents contribute to these impaired outcomes. Thus, the search for more potent antiplatelet treatment strategies is warranted in high-risk patients, such as those with DM. The present manuscript provides an overview on the current status of knowledge on currently available antiplatelet agents, focusing on the benefits and limitations of these therapies in DM patients, and evaluating the potential role of new antithrombotic agents and treatment strategies currently under development to overcome these limitations.
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Affiliation(s)
- José Luis Ferreiro
- IDIBELL-Hospital Universitari de Bellvitge, Department of Cardiology, Interventional Cardiology Unit, L'Hospitalet de Llobregat, Barcelona, Spain
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