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Peng X, Li Z, Li D, Li Z, Lu Z, Luo C, Ji Z. Bivalirudin Presents a Favorable Safety Profile Regarding Adverse Drug Reactions, Thrombocytopenia, and Bleeding in Chinese Patients With High Bleeding Risk Undergoing Percutaneous Coronary Intervention: A Prospective, Multi-Center, Intensive Monitoring Study. Front Cardiovasc Med 2022; 9:821322. [PMID: 37168321 PMCID: PMC10166107 DOI: 10.3389/fcvm.2022.821322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/29/2022] [Indexed: 05/13/2023] Open
Abstract
Background This study aimed to comprehensively explore the occurrence and risk factors for adverse events (AEs) and adverse drug reactions (ADRs) (especially for thrombocytopenia and bleeding) in Chinese patients with high bleeding risk (older adults, or complicated with diabetes mellitus or renal function impairment) undergoing percutaneous coronary intervention (PCI) with bivalirudin as an anticoagulant. Methods A total of 1,226 patients with high bleeding risk who received PCI with bivalirudin as an anticoagulant from 27 Chinese medical centers were enrolled in this prospective, multi-center, intensive monitoring study. AEs, ADRs, thrombocytopenia, and bleeding were collected from admission to 72 h post-bivalirudin administration; subsequently, patients were followed up on the 30th day with the safety data collected as well. Results Adverse events were observed in 198 (16.2) patients, among which severe AEs occurred in 16 (1.3%) patients. Meanwhile, bivalirudin-related ADRs were reported in 66 (5.4%) patients, among which 5 (0.4%) patients experienced bivalirudin-related severe ADRs. Besides, thrombocytopenia and bleeding occurred in 45 (3.7%) and 19 (1.5%) patients, respectively. The subsequent multivariate logistic analysis revealed that age >75 years [p = 0.017, odds ratio (OR) = 1.856] and spontaneous coronary artery dissection (SCAD) (p = 0.030, OR = 2.022) were independently related to higher ADR risk; SCAD (p = 0.017, OR = 2.426) was independently correlated with higher thrombocytopenia risk, while radial artery access (p = 0.015, OR = 0.352) was independently correlated with lower thrombocytopenia risk; and the administration of bivalirudin preoperatively or intraoperatively (p = 0.013, OR = 5.097) was independently associated with higher bleeding risk. Conclusion Bivalirudin presents a favorable safety profile regarding ADRs, thrombocytopenia, and bleeding in Chinese patients with high bleeding risk undergoing PCI.
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Affiliation(s)
- Xiaoping Peng
- Department of Cardiovascular, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhenyong Li
- Department of Cardiology, Xuzhou Central Hospital, Xuzhou, China
| | - Dunheng Li
- Department of Cardiology, Tai’an First People’s Hospital, Tai’an, China
| | - Zhongyin Li
- Department of Cardiovascular, Puyang Oilfield General Hospital, Puyang, China
| | - Zhaohua Lu
- Department of Cardiology, Wuzhou People’s Hospital, Wuzhou, China
| | - Caidong Luo
- Department of Cardiology, Mianyang Central Hospital, Mianyang, China
- *Correspondence: Caidong Luo,
| | - Zheng Ji
- First Department of Cardiology, Tangshan Worker’s Hospital, Tangshan, China
- Zheng Ji,
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Hu YC, Yao WJ, Jin DX, Zhang JX, Wang L, Zhang R, Xu JH, Cong HL. Bivalirudin in patients undergoing percutaneous coronary intervention and independent predictors of postoperative adverse events in these patients: A real world retrospective study. Medicine (Baltimore) 2021; 100:e25003. [PMID: 33725878 PMCID: PMC7969278 DOI: 10.1097/md.0000000000025003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 01/26/2021] [Accepted: 02/12/2021] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT The efficacy and safety of bivalirudin in percutaneous coronary intervention (PCI) has always been a hot topic in perioperative antithrombotic therapy, but there are still some controversies. So studies are needed to provide more evidence, especially the real world study which includes patients excluded from previous RCT studys. Our study aimed to investigate these information and analyze the independent predictors of postoperative adverse events.A retrospective study enrolled 1416 patients underwent PCI in Tianjin Chest Hospital from May 2016 to October 2017. The incidence of stent-thrombosis and net clinical adverse events, including all-cause death, myocardial infarction, stroke, urgent target-vessel revascularization and bleeding, were followed up for 30 days and 1 year. Logistic regression and COX regression were respectively used to analyze independent predictors of bleeding events within 30-days, and independent predictors of Major adverse cardiovascular and cerebrovascular events (MACCE) in patients with stent implantation within 1-year.Seven hundred six patients were treated with bivalirudin while 710 with unfractionated heparin (UFH). The proportions of diabetes, hypertension, anemia, myocardial-infarction history, PCI history, moderate-to-severe renal-impairment, gastrointestinal-bleeding history in the bivalirudin group were significantly higher (P < .05). Women, anemia were independent risk factors for bleeding within 30-days (P < .05). Among 682 patients with stent implantation in bivalirudin group, anemia, Body Mass Index (BMI) >25 kg/m2, KILLIP ≥2, ejection fraction (EF) <45%, eGFR <60 ml/minutes were independent risk factors for MACCE, while Statins, proton pump inhibitor (PPI) were independent protective factors for MACCE with-in 1-year (P < .05).Bivalirudin have good anticoagulant effect and lower bleeding risk during PCI, especially in patients with higher bleeding risk. In patients treated with bivalirudin, female, anemia were independent predictors of bleeding within 30-days, BMI >25 kg/m2, anemia, KILLIP ≥2, EF <45%, eGFR <60 ml/minutes were independent risk factors and Statins, PPI were independent protective factors of MACCE within 1-year.
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Affiliation(s)
- Yue-cheng Hu
- Department of Cardiology, Tianjin Chest Hospital
| | - Wei-jie Yao
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Dong-xia Jin
- Department of Cardiology, Tianjin Chest Hospital
| | | | - Le Wang
- Department of Cardiology, Tianjin Chest Hospital
| | - Rui Zhang
- Department of Cardiology, Tianjin Chest Hospital
| | - Jing-han Xu
- Department of Cardiology, Tianjin Chest Hospital
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Clinical Outcomes of Bivalirudin Versus Heparin in Elderly Patients Undergoing Percutaneous Coronary Intervention: a Systematic Review and Meta-analysis of Randomized Controlled Trials. Cardiovasc Drugs Ther 2020; 34:101-111. [PMID: 32100149 DOI: 10.1007/s10557-020-06937-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of this study was to explore the safety and efficacy of bivalirudin in elderly patients undergoing percutaneous coronary intervention (PCI). METHODS An electronic search was conducted for randomized controlled trials with outcomes of interest in the elderly (≥ 65 years of age). Pooled risk ratios (RR) and 95% confidence interval (CI) using random effects Der Simonian-Laird models were calculated. Primary outcomes were net adverse clinical events (NACE) and major bleeding events at 30 days. Secondary outcomes were major adverse cardiac events (MACE) at 30 days. MACE, all-cause mortality, and NACE at 6-12 months were also examined. RESULTS Eleven trials that randomized a total of 15,895 elderly patients undergoing PCI to bivalirudin versus heparin were included. At 30 days, bivalirudin was associated with a reduced risk of NACE (0.86 [0.75-0.99], p = 0.04), mainly driven by reduction in major bleeding events (0.66 [0.54-0.80], p < 0.0001), as compared with heparin. On subgroup analyses based on the use of GPI in the heparin arm, benefit of major bleeding associated with bivalirudin appeared to be equally evident when GPI was used as a bailout (0.66 [0.46-0.94], p = 0.02) versus routine (0.67 [0.51-0.88], p = 0.004) adjunctive therapy with heparin. Subgroup analyses stratified by clinical presentation showed that benefit of bivalirudin in reducing NACE was even more obvious in the elderly group presenting with ST segment elevation myocardial infarction (STEMI) (0.76 [0.65-0.89], p = 0.0007), as compared with the overall (acute coronary syndrome or stable ischemic heart disease) group. No difference in MACE (0.94 [0.82-1.09], p = 0.42) was demonstrated between the two groups. Bivalirudin was associated with a similar risk of NACE (0.74 [0.39-1.42], p = 0.36) at 6 months and MACE (0.90 [0.68-1.19], p = 0.45) at 6-12 months, while a non-statistically significant trend toward lower all-cause mortality (0.70 [0.47-1.06], p = 0.09) at 1 year. CONCLUSION In elderly patients undergoing PCI, bivalirudin was associated with a lower risk of major bleeding events and the magnitude of benefit was not related to the use of GPI and irrespective of clinical presentation. Bivalirudin may reduce the NACE, particularly in elderly patients presenting with STEMI or in the setting of routine GPI use in the heparin arm, while no difference in MACE was demonstrated between the two groups.
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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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Venetsanos D, Sederholm Lawesson S, Fröbert O, Omerovic E, Henareh L, Robertsson L, Linder R, Götberg M, James S, Alfredsson J, Erlinge D, Swahn E. Sex-related response to bivalirudin and unfractionated heparin in patients with acute myocardial infarction undergoing percutaneous coronary intervention: A subgroup analysis of the VALIDATE-SWEDEHEART trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 8:502-509. [DOI: 10.1177/2048872618803760] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims: Our aim was to study the impact of sex on anticoagulant treatment outcomes during percutaneous coronary intervention in acute myocardial infarction patients. Methods: This study was a prespecified analysis of the Bivalirudin versus Heparin in ST-Segment and Non ST-Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated according to Recommended Therapies Registry Trial (VALIDATE-SWEDEHEART) trial, in which patients with myocardial infarction were randomised to bivalirudin or unfractionated heparin during percutaneous coronary intervention. The primary outcome was the composite of death, myocardial infarction or major bleeding at 180 days. Results: There was a lower risk of the primary outcome in women assigned to bivalirudin than to unfractionated heparin (13.6% vs 17.1%, hazard ratio 0.78, 95% confidence interval (0.60–1.00)) with no significant difference in men (11.8% vs 11.2%, hazard ratio 1.06 (0.89–1.26), p for interaction 0.05). The observed difference was primarily due to lower risk of major bleeding (Bleeding Academic Research Consortium definition 2, 3 or 5) associated with bivalirudin in women (8.9% vs 11.8%, hazard ratio 0.74 (0.54–1.01)) but not in men (8.5% vs 7.3%, hazard ratio 1.16 (0.94–1.43) in men, p for interaction 0.02). Conversely, no significant difference in the risk of Bleeding Academic Research Consortium 3 or 5 bleeding, associated with bivalirudin, was found in women 4.5% vs 5.4% (hazard ratio 0.84 (0.54–1.31)) or men 2.9% vs 2.1% (hazard ratio 1.36 (0.93–1.99)). Bleeding Academic Research Consortium 2 bleeding occurred significantly less often in women assigned to bivalirudin than to unfractionated heparin. The risk of death or myocardial infarction did not significantly differ between randomised treatments in men or women. Conclusion: In women, bivalirudin was associated with a lower risk of adverse outcomes, compared to unfractionated heparin, primarily due to a significant reduction in Bleeding Academic Research Consortium 2 bleeds.
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Affiliation(s)
- D Venetsanos
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - S Sederholm Lawesson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - O Fröbert
- Department of Cardiology, Örebro University, Sweden
| | - E Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - L Henareh
- Department of Medicine, Karolinska Institute, Sweden
| | - L Robertsson
- Department of Cardiology, Södra Älvsborgs Sjukhus, Sweden
| | - R Linder
- Department of Cardiology, Danderyd Hospital, Sweden
| | - M Götberg
- Department of Cardiology, Skåne University Hospital, Sweden
| | - S James
- Department of Medical Sciences, Uppsala University, Sweden
| | - J Alfredsson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - D Erlinge
- Department of Cardiology, Skåne University Hospital, Sweden
| | - E Swahn
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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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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Efficacy and safety of bivalirudin for percutaneous coronary intervention in acute coronary syndromes: a meta-analysis of randomized-controlled trials. Clin Res Cardiol 2018; 107:807-815. [DOI: 10.1007/s00392-018-1251-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/09/2018] [Indexed: 11/25/2022]
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10
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Lima FV, Gruberg L, Aslam U, Ramgadoo M, Clase K, Trevisan A, Jeremias A. The impact of unfractionated heparin or bivalirudin on patients with stable coronary artery disease undergoing percutaneous coronary intervention. J Interv Cardiol 2017; 31:177-184. [PMID: 29205487 DOI: 10.1111/joic.12462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 09/24/2017] [Accepted: 10/03/2017] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES To compare bleeding and clinical events of patients with stable angina or silent ischemia undergoing percutaneous coronary intervention (PCI) treated with unfractionated heparin (UFH) or bivalirudin. BACKGROUND Few direct comparisons between UFH monotherapy versus bivalirudin exist for patients with stable ischemic heart disease undergoing PCI. METHODS A prospective, investigator-initiated, single-center, single-blinded, randomized trial of UFH versus bivalirudin was conducted. The primary endpoint was all bleeding (major and minor) from index-hospitalization to 30 days post discharge. Secondary endpoints included major adverse cerebral and cardiovascular events (MACCE) and net adverse clinical events (NACE). RESULTS Two-hundred-sixty patients were randomized for treatment with either UFH (n = 123) (47%) or bivalirudin (n = 137) (53%) There were no significant differences in baseline clinical and angiographic characteristics between the two groups. Primary endpoint was similar in both groups (10.9% with bivalirudin vs 7.3% with UFH [P = 0.31]). Major bleeding rates were 5.8% and 2.4%, respectively (P = 0.17). There was a higher MACCE (3.5% vs 0%, P = 0.03) and NACE (8.8% vs 2.4%, P = 0.03) rate with bivalirudin compared to UFH, respectively. Bivalirudin had increased odds of NACE (OR = 3.65, 95% CI: 1.00-13.3.6). Death and stent thrombosis rates were low and similar in both groups. Radial access was associated with fewer bleeding events compared to femoral access but not statistically significant (P = 0.29). CONCLUSIONS Among patients with stable angina or silent ischemia, there was no difference between UFH and bivalirudin in bleeding rates up to 30-days post-PCI. MACCE and NACE were higher among the bivalirudin group. Radial access was associated with a numerically lower rate of bleeding compared with femoral access.
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Affiliation(s)
- Fabio V Lima
- Department of Medicine, Brown University Rhode Island Hospital, Providence, Rhode Island
| | - Luis Gruberg
- Department of Cardiology, Hofstra Northwell School of Medicine, Northwell Health, Southside Hospital, Bay Shore, New York
| | - Usman Aslam
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,New York Institute of Technology, College of Osteopathic Medicine, Old Westbury, New York
| | - Melissa Ramgadoo
- Department of Medicine, Division of Cardiovascular Diseases, Stony Brook University Medical Center, Stony Brook, New York
| | - Kydanis Clase
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Alessandra Trevisan
- Department of Medicine, Division of Cardiovascular Diseases, Stony Brook University Medical Center, Stony Brook, New York.,Graduate Program in Public Health, Stony Brook University, Stony Brook, New York
| | - Allen Jeremias
- Department of Medicine, Division of Cardiology, St. Francis Hospital, The Heart Hospital, Roslyn, New York
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11
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Sullivan K, Wellsted D, Christopoulos C, Farag M, Gorog DA. Impaired thrombolytic status predicts adverse cardiac events in patients undergoing primary percutaneous coronary intervention. Thromb Haemost 2017; 117:457-470. [DOI: 10.1160/th16-09-0712] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/16/2016] [Indexed: 11/05/2022]
Abstract
SummaryAntithrombotic medications reduce thrombosis but increase bleeding. Identification of ST-elevation myocardial infarction (STEMI) patients at risk of recurrent thrombosis could allow targeted treatment with potent antithrombotic medications, with less potent agents in others, to reduce bleeding. Conventional platelet function tests assess platelet reactivity only, yet there is increasing evidence that endogenous thrombolytic potential determines outcome following thrombus initiation. We investigated whether assessing both platelet reactivity and endogenous thrombolysis, could identify STEMI patients at high-risk of recurrent thrombotic events. Thrombotic status was assessed in STEMI patients, before and after primary percutaneous coronary intervention (PPCI), at discharge and at 30 days; with 12 months’ followup. The time to form an occlusive thrombus under high shear (occlusion time, OT), and time to restore flow by endogenous thrombolysis (lysis time, LT) was measured using the point-of-care Global Thrombosis Test (GTT) in the cardiac catheterisation laboratory. Impaired endogenous thrombolysis (prolonged LT ≥ 3000 s), seen in 13 % patients pre-PPCI, was related to major adverse cardiac events, MACE (HR: 3.31, 95 %CI: 1.02–10.78, p = 0.045), driven by cardiovascular death (HR: 4.17, 95 %CI: 0.99–17.51, p = 0.05). Enhanced (rapid) endogenous thrombolysis (LT < 1000 s) was associated with spontaneous reperfusion, ST-segment resolution and Thrombolysis In Myocardial Infarction 3 flow pre-PPCI. Baseline OT was shorter in those with MACE (especially recurrent myocardial infarction and stroke) than those without (253 ± 150 s vs 354 ± 134 s, p=0.017). Endogenous thrombolysis, when impaired, is associated with increased cardiovascular risk, and when enhanced, with spontaneous reperfusion. Endogenous thrombolysis may be a novel target for pharmacological intervention, and allow targeting of potent antithrombotic medications to high-risk patients.
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12
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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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13
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Tandjung K, Lam MK, Sen H, de Man FHAF, Louwerenburg JHW, Stoel MG, van Houwelingen KG, Linssen GCM, van der Palen J, Doggen CJM, von Birgelen C. Value of the SYNTAX score for periprocedural myocardial infarction according to WHO and the third universal definition of myocardial infarction: insights from the TWENTE trial. EUROINTERVENTION 2017; 12:431-40. [PMID: 26342469 DOI: 10.4244/eijy15m08_01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The SYNTAX score is a tool to quantify the complexity of coronary artery disease. We investigated the relation between the SYNTAX score and the occurrence of a periprocedural myocardial infarction (PMI) according to the historical definition of the World Health Organization (WHO) and the recently updated universal definition of MI. METHODS AND RESULTS The SYNTAX score was calculated in 1,243 patients enrolled in TWENTE, a randomised trial which assessed second-generation drug-eluting stents. PMI was defined by the WHO definition and the third universal definition of MI. Patients were divided into tertiles of the SYNTAX score: ≤7 (n=430); >7 and <15 (n=390); ≥15 (n=423). PMI according to the WHO definition occurred more frequently in patients in the highest SYNTAX score tertile (7.3% vs. 3.1% vs. 1.6%, p<0.001) compared to the mid and lowest tertile. Similar findings were seen for universal PMI (9.9% vs. 7.7% vs. 3.7%, p<0.01). After multivariate analysis, SYNTAX score was a significant independent correlate of PMI for both definitions: the highest SYNTAX score tertile had an almost five times higher risk for WHO PMI, and a three times higher risk for universal PMI. CONCLUSIONS In a broad patient population treated with second-generation DES, the SYNTAX score was able to stratify the risk of PMI.
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Affiliation(s)
- Kenneth Tandjung
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
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14
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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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15
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Mina GS, Firouzbakht T, Modi K, Dominic P. Gender-based outcomes of bivalirudin versus heparin in patients undergoing percutaneous coronary interventions: Meta-analysis of randomized controlled trials. Catheter Cardiovasc Interv 2017; 90:735-742. [PMID: 28339139 DOI: 10.1002/ccd.26985] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 10/26/2016] [Accepted: 01/22/2017] [Indexed: 01/26/2023]
Abstract
OBJECTIVES We aimed to perform a gender-based meta-analysis of the outcome of bivalirudin versus heparin in patients undergoing percutaneous coronary interventions (PCI). BACKGROUND Bivalirudin has been shown to decrease major bleeding when compared to heparin ± glycoprotein IIb/IIIa inhibitors (GPI) in patients undergoing PCI. It is unclear, however, if those differences in outcomes are the same for men and women. METHODS We included randomized controlled trials (RCTs) that compared bivalirudin to heparin with or without GPI in patients undergoing PCI and reported outcome data that were stratified by gender. Random effect model was used to pool odds ratio (OR) and 95% confidence intervals (CI). RESULTS We included 9 trials with 33,224 patients. Bivalirudin decreased major bleeding when compared to heparin plus routine GPI in both men (OR: 0.51, P < 0.001) and women (OR: 0.55, P < 0.001). However, when GPI were used selectively with heparin, the bleeding lowering effect of bivalirudin was statistically significant in men (OR: 0.69, P = 0.02) but not in women (OR: 0.71, P = 0.21). When compared to heparin ± GPI, there was a nonstatistically significant trend toward lower all-cause mortality with bivalirudin in both men (OR: 0.76, P = 0.055) and women (OR: 0.79, P = 0.21). There were no significant differences in major adverse cardiovascular events between heparin and bivalirudin in both men and women. CONCLUSION Bivalirudin decreases major bleeding in both men and women when compared to heparin plus routine GPI. However, when compared to heparin alone, the bleeding lowering benefit of bivalirudin is less evident in women. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- George S Mina
- Department of Cardiology, LSUHSC-Shreveport, Shreveport, Louisiana
| | - Tina Firouzbakht
- Department of Medicine, LSUHSC-Shreveport, Shreveport, Louisiana
| | - Kalgi Modi
- Department of Cardiology, LSUHSC-Shreveport, Shreveport, Louisiana
| | - Paari Dominic
- Department of Cardiology, LSUHSC-Shreveport, Shreveport, Louisiana
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16
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Ghobrial J, Burke DA, Pinto DS. Role of Parenteral Agents in PCI for Stable Patients. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Joanna Ghobrial
- Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
| | - David A. Burke
- Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
| | - Duane S. Pinto
- Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
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17
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Comparison of heparin, bivalirudin, and different glycoprotein IIb/IIIa inhibitor regimens for anticoagulation during percutaneous coronary intervention: A network meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2016; 17:535-545. [PMID: 27842901 DOI: 10.1016/j.carrev.2016.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 09/26/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND/PURPOSE Numerous GPIs are available for PCI. Although they were tested in randomized controlled trials, a comparison between the different GPI strategies is lacking. Thus, we performed a Bayesian network meta-analysis to compare different glycoprotein IIb/IIIa inhibitor (GPI) strategies with heparin and bivalirudin for percutaneous coronary intervention (PCI). METHODS MEDLINE, Cochrane CENTRAL, and ClinicalTrials.gov were searched by two independent reviewers for randomized controlled trials comparing high-dose bolus tirofiban, abciximab, eptifibatide, heparin with provisional glycoprotein IIb/IIIa inhibitors, and bivalirudin with provisional GPI that reported clinical outcomes. Mixed treatment comparison model generation was performed to directly and indirectly compare between different anticoagulation strategies for all-cause mortality, myocardial infarction, major adverse cardiovascular events, major bleeding, minor bleeding, need for transfusion, and thrombocytopenia. RESULTS A total of 41 randomized controlled trials with 38,645 patients were included in the analysis, among which 2654 were randomized to high-dose bolus tirofiban, 6752 to abciximab, 1669 to eptifibatide, 16,500 to heparin, and 11,070 to bivalirudin. Mean age was 64±11years, 75% were male, 91% were treated with stenting, 71% with clopidogrel, and 74% for acute coronary syndrome. High-dose bolus tirofiban was associated with a significant reduction in all-cause mortality compared with heparin (OR 0.57 [credible intervals 0.37, 0.9]) and eptifibatide (OR 0.44 [credible intervals 0.19, 1.0]). GPI regimens had less myocardial infarction and major adverse cardiovascular events but greater bleeding compared with heparin and bivalirudin. There was no difference among the GPI therapies for other outcomes, including myocardial infarction, major adverse cardiovascular events, and major bleeding. CONCLUSIONS Our network meta-analysis of 38,645 patients demonstrated that GPI regimens were associated with a reduction in recurrent myocardial infarction or major adverse cardiovascular events for PCI, while bivalirudin was associated with the lowest risk of bleeding.
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18
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Centurión OA. Heparin Versus Bivalirudin in Acute Myocardial Infarction: Unfractionated Heparin Monotherapy Elevated to Primary Treatment in Contemporary Percutaneous Coronary Intervention. Open Cardiovasc Med J 2016; 10:122-9. [PMID: 27583038 PMCID: PMC5002443 DOI: 10.2174/1874192401610010122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 03/20/2015] [Accepted: 04/22/2015] [Indexed: 11/22/2022] Open
Abstract
Bivalirudin, a direct thrombin inhibitor, was developed as an antithrombin agent for patients undergoing percutaneous coronary interventions (PCI) with the hypothesis that it would reduce bleeding complications without compromising the rate of ischemic events compared to heparin plus GP IIb/IIIa inhibitors. Although the cumulative evidence makes a strong argument for the use of bivalirudin rather than heparin plus systematic GP IIb/IIIa inhibitors for the great majority of patients with acute myocardial infarction (AMI) undergoing PCI, the benefit observed with bivalirudin was achieved because of the major bleeding complications with the use of heparin plus GP IIb/IIIa inhibitors. When bivalirudin was compared with unfractionated heparin alone there was no benefit in ischemic complications with a decrease in major bleeding. However, in a recent large randomized controlled trial comparing bivalirudin with unfractionated heparin alone in AMI patients undergoing primary PCI, bivalirudin did not reduce bleeding complications and was associated with higher rates of stent thrombosis, myocardial reinfarction, and repeat revascularization compared with heparin. Moreover, 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 AMI patients done by myself and published almost five years ago in this journal, I rendered some reflections on the future widespread use of bivalirudin. “In the setting of PCI in AMI patients, 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 alone. 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 AMI patients”. Therefore, instead of being the beginning of a new era with bivalirudin, it sure is 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, as monotherapy and preferred anticoagulant regimen for contemporary PCI in AMI patients.
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Affiliation(s)
- Osmar Antonio Centurión
- Department of Cardiology, Clínic Hospital, Asunción National University, Cardiovascular Institute, Sanatorio Migone-Battilana, Asunción, Paraguay
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19
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Erlinge D, Koul S, Eriksson P, Scherstén F, Omerovic E, Linder R, Östlund OP, Wallentin L, Fröbert O, James S. Bivalirudin versus heparin in non-ST and ST-segment elevation myocardial infarction-a registry-based randomized clinical trial in the SWEDEHEART registry (the VALIDATE-SWEDEHEART trial). Am Heart J 2016; 175:36-46. [PMID: 27179722 DOI: 10.1016/j.ahj.2016.02.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 02/07/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND The optimal anticoagulant for patients with acute coronary syndrome treated with percutaneous coronary intervention (PCI) has not been validated in current practice of radial approach and pretreatment with potent P2Y12 inhibitors. Several studies have indicated increased bleeding rate and, in some instances, even increased mortality by the routine use of heparin and glycoprotein IIb/IIIa inhibitors compared to bivalirudin. Direct comparison of bivalirudin versus heparin alone has yielded contradictory results depending on study designs. METHODS/DESIGN The VALIDATE-SWEDEHEART trial is a multicenter, prospective, randomized, registry-based, controlled, and open-label clinical trial in patients with ST-segment elevation myocardial infarction (STEMI) or non-STEMI undergoing PCI pretreated with ticagrelor, prasugrel, or cangrelor. We hypothesize that bivalirudin is superior to heparin alone in reducing death, myocardial infarction, and major bleeding events at 180 days (primary end point). The trial will enroll 3,000 patients with STEMI and 3,000 patients with non-STEMI undergoing PCI. The trial will use a hybrid registry-based randomized clinical trial design where inclusion, randomization, and baseline data collection are performed using The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry. The primary composite end point (death, myocardial infarction, or major bleeding events at 180 days) will be identified through active screening after 7 and 180 days and adjudicated by a blinded central end point committee. Secondary end points and long-term outcomes will be recorded from national registries. CONCLUSION The VALIDATE-SWEDEHEART trial is founded on a nationwide clinical registry and uses a hybrid registry-based randomized clinical trial (RRCT) design methodology to evaluate efficacy and safety of bivalirudin as compared to heparin alone for acute coronary syndrome, in a large population receiving contemporary recommended therapies including predominantly radial invasive approach and pretreatment with potent P2Y12 inhibitors.
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Affiliation(s)
- David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden.
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | | | - Fredrik Scherstén
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University, Gothenburg, Sweden
| | - Rikard Linder
- Department of Cardiology, Danderyd, Karolinska University, Stockholm, Sweden
| | - Olof Petter Östlund
- Department of Medical Sciences, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Lars Wallentin
- Department of Medical Sciences, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Ole Fröbert
- Department of Cardiology, Faculty of Health, Örebro University, Sweden
| | - Stefan James
- Department of Medical Sciences, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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20
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Barria Perez AE, Rao SV, Jolly SJ, Pancholy SB, Plourde G, Rimac G, Poirier Y, Costerousse O, Bertrand OF. Meta-Analysis of Effects of Bivalirudin Versus Heparin on Myocardial Ischemic and Bleeding Outcomes After Percutaneous Coronary Intervention. Am J Cardiol 2016; 117:1256-66. [PMID: 26899489 DOI: 10.1016/j.amjcard.2016.01.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/22/2016] [Accepted: 01/22/2016] [Indexed: 11/15/2022]
Abstract
Bivalirudin is an alternative to unfractionated heparin (UFH) anticoagulation during percutaneous coronary intervention. Previously, we have reported clinical benefit on major bleeding in favor of bivalirudin compared with UFH monotherapy but inconclusive results on mortality. Controversial data have been reported in the last 2 years. We conducted an updated meta-analysis including randomized trials and observational studies, which evaluated ischemic and bleeding outcomes for bivalirudin compared with UFH-only during percutaneous coronary intervention. We included 18 observational studies and 12 randomized trials published from 2003 to 2015. Primary outcomes were major adverse cardiovascular events within 30 days including death, myocardial infarction, and urgent revascularization and stent thrombosis, major bleeding, and transfusion. Overall, we found a significant risk reduction with bivalirudin for major bleeding (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.49 to 0.71, p <0.0001) and for transfusion (OR 0.79, 95% CI 0.66 to 0.95, p = 0.01) and similar risk for major adverse cardiovascular events (OR 0.98, 95% CI 0.86 to 1.12, p = 0.80). However, there was a substantial increased risk of stent thrombosis associated with bivalirudin (OR 1.52, 95% CI 1.11 to 2.08, p = 0.009). No impact on mortality was found. Meta-regression analyses on major bleeding suggested that bivalirudin was more effective than UFH at doses >60 IU/kg and independent of radial access. In conclusion, compared with UFH monotherapy, bivalirudin remains associated with less bleeding risk but higher stent thrombosis risk. Further study remains required to define its role in current antithrombotic armamentarium.
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Affiliation(s)
| | - Sunil V Rao
- Duke Clinical Research Institute, Durham, North Carolina
| | - Sanjit J Jolly
- McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Samir B Pancholy
- The Wright Center for Graduate Medical Education, The Common Wealth Medical College, Scranton, Pennsylvania
| | | | - Goran Rimac
- Quebec Heart-Lung Institute, Quebec, Quebec, Canada
| | - Yann Poirier
- Quebec Heart-Lung Institute, Quebec, Quebec, Canada
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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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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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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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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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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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Cassese S, Byrne RA, Laugwitz KL, Schunkert H, Berger PB, Kastrati A. Bivalirudin versus heparin in patients treated with percutaneous coronary intervention: a meta-analysis of randomised trials. EUROINTERVENTION 2015; 11:196-203. [DOI: 10.4244/eijy14m08_01] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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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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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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Abtahian F, Waldo S, Jang IK. Comparison of heparin and bivalirudin in patients undergoing percutaneous coronary intervention without use of glycoprotein IIb/IIIa inhibitors. Catheter Cardiovasc Interv 2015; 86:390-6. [PMID: 25753749 DOI: 10.1002/ccd.25911] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 02/28/2015] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The primary objective of this study is the compare the association between bleeding and the use unfractionated heparin (UFH) versus bivalirudin during percutaneous coronary intervention (PCI). BACKGROUND In patients undergoing PCI, the risk of bleeding with use of bivalirudin compared with UFH in the absence of glycoprotein IIb/IIIa inhibitors is not well defined. METHODS Patients undergoing PCI with either UFH or bivalirudin monotherapy at a single institution between 2007 and 2014 were included (n = 6,143). Propensity score matching was used to adjust for baseline characteristics yielding 2,984 well matched patients (1,492 in each group). The primary endpoint was major non-coronary artery bypass graft (non-CABG) related bleeding as defined by a Bleeding Academic Consortium type 3 or 5. Secondary outcomes included combined major and minor bleeding, in-hospital death, periprocedural myocardial infarction, and recurrent ischemia requiring urgent revascularization (repeat PCI). RESULTS In the propensity matched cohort, there was no difference in major bleeding between UFH and bivalirudin monotherapy (1.8% versus 2.4%, P = 0.305). Combined major and minor bleeding was also similar between the two groups (4.3% versus 4.3%, P = 1.0). Likewise, no differences were observed between the bivalirudin and UFH groups in terms of in-hospital death (0.4% versus 0.5%, P = 0.592), periprocedural myocardial infarction (1.5% versus 2.0%, P = 0.332) and repeat PCI (0.7% versus 0.8%, P = 0.669). CONCLUSION Among patients undergoing PCI, there was no significant difference in rate of bleeding between bivalirudin and heparin monotherapy in a real-world setting.
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Affiliation(s)
- Farhad Abtahian
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachuttes
| | - Stephen Waldo
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachuttes
| | - Ik-Kyung Jang
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachuttes
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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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Briguori C, Visconti G, Focaccio A, Donahue M, Golia B, Selvetella L, Ricciardelli B. Novel approaches for preventing or limiting events (Naples) III trial: randomized comparison of bivalirudin versus unfractionated heparin in patients at increased risk of bleeding undergoing transfemoral elective coronary stenting. JACC Cardiovasc Interv 2015; 8:414-423. [PMID: 25703878 DOI: 10.1016/j.jcin.2014.10.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 10/07/2014] [Accepted: 10/08/2014] [Indexed: 12/22/2022]
Abstract
OBJECTIVES This study sought to assess the safety and the efficacy of bivalirudin compared with unfractionated heparin (UFH) alone in the subset of patients at increased risk of bleeding undergoing transfemoral elective percutaneous coronary intervention (PCI). BACKGROUND Bivalirudin, a synthetic direct thrombin inhibitor, determines a significant decrease of in-hospital bleeding following PCI. METHODS This is a single-center, investigator-initiated, randomized, double-blind, controlled trial. Consecutive biomarker-negative patients at increased bleeding risk undergoing PCI through the femoral approach were randomized to UFH (UFH group; n = 419) or bivalirudin (bivalirudin group; n = 418). The primary endpoint was the rate of in-hospital major bleeding. RESULTS The primary endpoint occurred in 11 patients (2.6%) in the UFH group versus 14 patients (3.3%) in the bivalirudin group (odds ratio: 0.78; 95% confidence interval: 0.35 to 1.72; p = 0.54). Distribution of access-site and non-access-site bleeding was 18% and 82% in the UFH group versus 50% and 50% in the bivalirudin group (p = 0.10). CONCLUSIONS The results of this randomized study, carried out at a single institution, suggest that there is no difference in major bleeding rate between bivalirudin and UFH in increased-risk patients undergoing transfemoral PCI. (Novel Approaches in Preventing and Limiting Events III Trial: Bivalirudin in High-Risk Bleeding Patients [NAPLES III]; NCT01465503).
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Affiliation(s)
- Carlo Briguori
- Department of Cardiology, Clinica Mediterranea, Naples, Italy.
| | | | - Amelia Focaccio
- Department of Cardiology, Clinica Mediterranea, Naples, Italy
| | - Michael Donahue
- Department of Cardiology, Clinica Mediterranea, Naples, Italy
| | - Bruno Golia
- Department of Cardiology, Clinica Mediterranea, Naples, 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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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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Navarese EP, Schulze V, Andreotti F, Kowalewski M, Kołodziejczak M, Kandzari DE, Rassaf T, Gorny B, Brockmeyer M, Meyer C, Berti S, Kubica J, Kelm M, Valgimigli M. Comprehensive Meta-Analysis of Safety and Efficacy of Bivalirudin Versus Heparin With or Without Routine Glycoprotein IIb/IIIa Inhibitors in Patients With Acute Coronary Syndrome. JACC Cardiovasc Interv 2015; 8:201-213. [DOI: 10.1016/j.jcin.2014.10.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 10/08/2014] [Indexed: 10/24/2022]
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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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Pappalardo F, Agracheva N, Covello RD, Pieri M, De Bonis M, Calabrò MG, Koster A, Zangrillo A. Anticoagulation for Critically Ill Cardiac Surgery Patients: Is Primary Bivalirudin the Next Step? J Cardiothorac Vasc Anesth 2014; 28:1013-17. [DOI: 10.1053/j.jvca.2013.10.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Indexed: 11/11/2022]
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40
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Akin I, Khattab AA, Büttner HJ, Toelg R, Geist V, Neumann FJ, Richardt G, Abdel-Wahab M. Comparison of bivalirudin and heparin in patients undergoing rotational atherectomy: a subanalysis of the randomised ROTAXUS trial. EUROINTERVENTION 2014; 10:458-65. [DOI: 10.4244/eijv10i4a79] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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41
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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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42
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Patti G, Proscia C, Di Sciascio G. Antiplatelet Therapy in Patients With Diabetes Mellitus and Acute Coronary Syndrome. Circ J 2014; 78:33-41. [DOI: 10.1253/circj.cj-13-0742] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Giuseppe Patti
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome
| | - Claudio Proscia
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome
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Perdoncin E, Zhang M, Riba A, LaLonde TA, Grines CL, Gurm HS. Impact of Worsening Renal Dysfunction on the Comparative Efficacy of Bivalirudin and Platelet Glycoprotein IIb/IIIa Inhibitors. Circ Cardiovasc Interv 2013; 6:688-93. [DOI: 10.1161/circinterventions.113.000554] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Use of bivalirudin has been associated with a reduction in the incidence of bleeding in patients undergoing percutaneous coronary intervention. Patients with chronic kidney disease, a known predictor of post–percutaneous coronary intervention bleeding, are under-represented in clinical trials.
Methods and Results—
We evaluated the outcome of 64 052 patients who underwent percutaneous coronary intervention from 2007 to 2009 at 33 hospitals in Michigan and were treated with bivalirudin (28 378) or with heparin and glycoprotein IIb/IIIa inhibitors (35 674). Propensity-matched analysis was adjusted for the nonrandomized use of the 2 strategies. Patients treated with bivalirudin were older, had a lower glomerular filtration rate, and had more comorbidities. Use of bivalirudin was associated with fewer transfusions (2.8% versus 4.2%;
P
<0.0001), gastrointestinal bleeds (0.5% versus 1.3%;
P
<0.0001), and vascular complications (1.0% versus 2.5%;
P
<0.0001), with no difference in survival. Bleeding complications were more common with worsening renal function, but use of bivalirudin was associated with less bleeding across the continuum of renal dysfunction.
Conclusions—
The risk of bleeding after percutaneous coronary intervention increases with worsening chronic kidney disease. Bivalirudin was associated with a dramatically reduced risk of bleeding across all categories of renal dysfunction. Our study findings suggest that bivalirudin monotherapy is an acceptable, if not the more appropriate alternative, to heparin and glycoprotein IIb/IIIa inhibitors in patients with chronic kidney disease.
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Affiliation(s)
- Emily Perdoncin
- From the Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor (E.P., H.S.G.); Department of Biostatistics, University of Michigan, Ann Arbor (M.Z.); Department of Internal Medicine, Oakwood Hospital and Medical Center, Dearborn, MI (A.R.); Department of Internal Medicine, St. John Providence Health System, Detroit, MI (T.A.L.); and Department of Internal Medicine, Detroit Medical Center, MI (C.L.G.)
| | - Min Zhang
- From the Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor (E.P., H.S.G.); Department of Biostatistics, University of Michigan, Ann Arbor (M.Z.); Department of Internal Medicine, Oakwood Hospital and Medical Center, Dearborn, MI (A.R.); Department of Internal Medicine, St. John Providence Health System, Detroit, MI (T.A.L.); and Department of Internal Medicine, Detroit Medical Center, MI (C.L.G.)
| | - Arthur Riba
- From the Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor (E.P., H.S.G.); Department of Biostatistics, University of Michigan, Ann Arbor (M.Z.); Department of Internal Medicine, Oakwood Hospital and Medical Center, Dearborn, MI (A.R.); Department of Internal Medicine, St. John Providence Health System, Detroit, MI (T.A.L.); and Department of Internal Medicine, Detroit Medical Center, MI (C.L.G.)
| | - Thomas A. LaLonde
- From the Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor (E.P., H.S.G.); Department of Biostatistics, University of Michigan, Ann Arbor (M.Z.); Department of Internal Medicine, Oakwood Hospital and Medical Center, Dearborn, MI (A.R.); Department of Internal Medicine, St. John Providence Health System, Detroit, MI (T.A.L.); and Department of Internal Medicine, Detroit Medical Center, MI (C.L.G.)
| | - Cindy L. Grines
- From the Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor (E.P., H.S.G.); Department of Biostatistics, University of Michigan, Ann Arbor (M.Z.); Department of Internal Medicine, Oakwood Hospital and Medical Center, Dearborn, MI (A.R.); Department of Internal Medicine, St. John Providence Health System, Detroit, MI (T.A.L.); and Department of Internal Medicine, Detroit Medical Center, MI (C.L.G.)
| | - Hitinder S. Gurm
- From the Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor (E.P., H.S.G.); Department of Biostatistics, University of Michigan, Ann Arbor (M.Z.); Department of Internal Medicine, Oakwood Hospital and Medical Center, Dearborn, MI (A.R.); Department of Internal Medicine, St. John Providence Health System, Detroit, MI (T.A.L.); and Department of Internal Medicine, Detroit Medical Center, MI (C.L.G.)
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van Es N, Bleker SM, Büller HR, Coppens M. New developments in parenteral anticoagulation for arterial and venous thromboembolism. Best Pract Res Clin Haematol 2013; 26:203-13. [DOI: 10.1016/j.beha.2013.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Nick van Es
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
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Sergie Z, Lefèvre T, Van Belle E, Kakoulides S, Baber U, Deliargyris EN, Mehran R, Grube E, Reinöhl J, Dangas GD. Current periprocedural anticoagulation in transcatheter aortic valve replacement: could bivalirudin be an option? Rationale and design of the BRAVO 2/3 studies. J Thromb Thrombolysis 2013; 35:483-93. [DOI: 10.1007/s11239-013-0890-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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46
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Meta-analysis comparing bivalirudin versus heparin monotherapy on ischemic and bleeding outcomes after percutaneous coronary intervention. Am J Cardiol 2012; 110:599-606. [PMID: 22591669 DOI: 10.1016/j.amjcard.2012.03.051] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Revised: 03/27/2012] [Accepted: 03/27/2012] [Indexed: 11/20/2022]
Abstract
With femoral access, bivalirudin decreases risks of major bleeding after percutaneous coronary intervention (PCI) and provides better net clinical benefit compared to unfractionated heparin (UFH) plus planned glycoprotein IIb/IIIa inhibitors. Whether this benefit exists compared to UFH monotherapy is less clear. We performed a systematic review and meta-analysis to compare outcomes in patients undergoing transfemoral PCI with UFH or bivalirudin. Randomized trials (n = 3) and observational studies (n = 13) comparing bivalirudin to UFH monotherapy were reviewed. Primary outcomes were 30-day rates of major adverse cardiovascular events (MACEs) including death, myocardial infarction (MI), urgent revascularization, as well as all-cause mortality, MI, major bleeding, and blood transfusion. We collected data from 16 studies involving 32,492 patients undergoing PCI. Most observational studies were performed in the United States, whereas all randomized trials were done in Europe. Compared to UFH monotherapy, bivalirudin was associated with similar risk of MACEs (odds ratios [OR] 0.92, 95% confidence interval [CI] 0.75 to 1.12), a substantial 45% relative decrease in major bleeding (OR 0.55, 95% CI 0.43 to 0.72), and a trend in the decrease of transfusion (OR 0.87, 95% CI 0.70 to 1.08). A decrease in mortality was seen in observational studies (OR 0.62, 95% CI 0.45 to 0.85) but remained inconclusive in randomized trials (OR 0.63, 95% CI 0.20 to 2.01). MI rate was similar with the 2 anticoagulants. In conclusion, in patients undergoing transfemoral PCI, the benefit of bivalirudin over UFH monotherapy is driven by a significant decrease in major bleeding with similar rates of MACE. As PCI practice moves toward other bleeding-avoidance strategies such as the radial approach, future studies should focus on the interaction between anticoagulant strategy and access-site choice.
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