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Lipinski MJ. Editorial: Bivalirudin with post-procedural infusion: Should the Guidelines change to keep up with the data? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 57:80-81. [PMID: 37661529 DOI: 10.1016/j.carrev.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/09/2023] [Indexed: 09/05/2023]
Affiliation(s)
- Michael J Lipinski
- Cardiovascular Associates of Charlottesville and Sentara Martha Jefferson Hospital, Charlottesville, VA, United States of America.
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Benenati S, De Maria GL, Della Mora F, Portolan L, Kotronias R, Kharbanda RK, Porto I, Banning AP. Periprocedural antithrombotic strategies in acute coronary syndromes undergoing percutaneous coronary intervention: Have we discarded bivalirudin too soon? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 57:70-79. [PMID: 37349187 DOI: 10.1016/j.carrev.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/15/2023] [Accepted: 06/14/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Publication of the BRIGHT-4 trial results has restimulated discussion about the optimal periprocedural antithrombotic strategy for patients undergoing percutaneous coronary intervention (PCI) with acute coronary syndromes (ACS). It is possible that variation in the infusion duration, may contribute to observed differences in safety-efficacy profiles of bivalirudin in this clinical setting. METHODS Up to December 2022, randomized controlled trials (RCTs) comparing bivalirudin (either administered peri-procedurally or accompanied by postprocedural infusion) and heparin, both with or without GPI, were searched and entered in a frequentist network meta-analysis. Co-primary endpoints were trial-defined major adverse composite events (MACE) and major bleeding. Incident rate ratios (IRR) and 95 % confidence intervals (CI) were estimated. RESULTS 10 RCTs (N = 57,137 patients/month) were included. As compared to heparin, prolonged bivalirudin infusion resulted in lower rates of major bleeding (IRR 0.58, 95 % CI 0.36-0.91), but there was no differences in MACE rates between these strategies. With regard to NACE, prolonged bivalirudin infusion yielded lower risk (IRR 0.86, 95 % CI 0.77-0.96), whereas both bivalirudin and heparin increased risk when coupled with GPI (IRR 1.24, 95 % CI 1.01-1.51 and IRR 1.24, 95 % CI 1.06-1.44, respectively). Both these combination strategies also increased minor bleeding rates (IRR 1.49, 95 % CI 1.16-1.93 and IRR 1.58, 95 % CI 1.29-1.95, respectively, for bivalirudin and heparin). Results were consistent across several sensitivity analyses. CONCLUSION In patients with ACS undergoing PCI, procedural bivalirudin administration followed by prolonged infusion results in lower major bleeding rates, but there does not appear to be a difference in observed MACE.
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Affiliation(s)
- Stefano Benenati
- Cardiovascular Disease Chair, Department of Internal Medicine (Di.M.I.), University of Genoa, Genoa, Italy; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Francesco Della Mora
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom; Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Leonardo Portolan
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom; Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Rafail Kotronias
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Rajesh K Kharbanda
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Italo Porto
- Cardiovascular Disease Chair, Department of Internal Medicine (Di.M.I.), University of Genoa, Genoa, Italy; Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genova, Italy
| | - Adrian P Banning
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom.
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Bikdeli B, Stone GW. Bivalirudin bewilderment. Kardiol Pol 2018; 76:711-712. [PMID: 29652420 DOI: 10.5603/kp.2018.0074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 03/02/2018] [Indexed: 11/25/2022]
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Lipinski MJ, Escarcega RO, Baker NC, Benn HA, Gaglia MA, Torguson R, Waksman R. Scaffold Thrombosis After Percutaneous Coronary Intervention With ABSORB Bioresorbable Vascular Scaffold: A Systematic Review and Meta-Analysis. JACC Cardiovasc Interv 2016; 9:12-24. [PMID: 26762906 DOI: 10.1016/j.jcin.2015.09.024] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 08/27/2015] [Accepted: 09/10/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The aim of this study was to determine the risk of scaffold thrombosis (ST) after percutaneous coronary intervention (PCI) with placement of an ABSORB bioresorbable vascular scaffold (BVS) (Abbott Vascular, Santa Clara, California) by conducting a systematic review and meta-analysis. BACKGROUND PCI with BVS placement holds great potential, but concern has recently been raised regarding the risk of ST. METHODS MEDLINE/PubMed, Cochrane CENTRAL, and meeting abstracts were searched for all studies that included outcomes data for patients after PCI with BVS placement. For studies comparing BVSs with drug-eluting stents (DES), pooled estimates of outcomes, presented as odds ratios (ORs) with 95% confidence intervals (CIs), were generated with random-effects models. RESULTS Our analysis included 10,510 patients (8,351 with a BVS and 2,159 with DES) with a follow-up of 6.4 ± 5.1 months and 60 ± 11 years of age; 78% were male, 36% had stable angina, and 59% had acute coronary syndrome (ACS). Among patients with a BVS, cardiovascular death occurred in 0.6%, myocardial infarction (MI) in 2.1%, target lesion revascularization in 2.0%, and definite/probable ST in 1.2% of patients. Of BVS patients, 0.27% had acute ST and 0.57% had subacute ST. Meta-analysis demonstrated that patients who received a BVS were at a higher risk of MI (OR: 2.06, 95% CI: 1.31 to 3.22, p = 0.002) and definite/probable ST (OR: 2.06, 95% CI: 1.07 to 3.98, p = 0.03) compared with patients who received DES, whereas there was a trend toward decreased all-cause mortality with a BVS (OR: 0.40, 95% CI: 0.15 to 1.06, p = 0.06). CONCLUSIONS Patients undergoing PCI with a BVS had increased definite/probable ST and MI during follow-up compared with DES. Further studies with long-term follow-up are needed to assess the risk of ST with a BVS.
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Affiliation(s)
- Michael J Lipinski
- MedStar Cardiovascular Research Network, MedStar Washington Hospital Center, Washington, DC
| | - Ricardo O Escarcega
- MedStar Cardiovascular Research Network, MedStar Washington Hospital Center, Washington, DC
| | - Nevin C Baker
- MedStar Cardiovascular Research Network, MedStar Washington Hospital Center, Washington, DC
| | - Hadiya A Benn
- MedStar Cardiovascular Research Network, MedStar Washington Hospital Center, Washington, DC
| | - Michael A Gaglia
- MedStar Cardiovascular Research Network, MedStar Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- MedStar Cardiovascular Research Network, MedStar Washington Hospital Center, Washington, DC
| | - Ron Waksman
- MedStar Cardiovascular Research Network, MedStar Washington Hospital Center, Washington, DC.
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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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Gargiulo G, Valgimigli M. Bivalirudin Versus Unfractionated Heparin for Acute Coronary Syndromes: Do We Have a Winner? REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2016; 69:721-724. [PMID: 27349877 DOI: 10.1016/j.rec.2016.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 04/18/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Giuseppe Gargiulo
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland.
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Gargiulo G, Valgimigli M. Bivalirudina frente a heparina no fraccionada en síndromes coronarios agudos: ¿hay un vencedor? Rev Esp Cardiol (Engl Ed) 2016. [DOI: 10.1016/j.recesp.2016.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Incorporating linked healthcare claims to improve confounding control in a study of in-hospital medication use. Drug Saf 2016; 38:589-600. [PMID: 25935198 DOI: 10.1007/s40264-015-0292-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The Premier Perspective hospital billing database provides a promising data source for studies of inpatient medication use. However, in-hospital recording of confounders is limited, and incorporating linked healthcare claims data available for a subset of the cohort may improve confounding control. We investigated methods capable of adjusting for confounders measured in a subset, including complete case analysis, multiple imputation of missing data, and propensity score (PS) calibration. METHODS Methods were implemented in an example study of adults in Premier undergoing percutaneous coronary intervention (PCI) in 2004-2008 and exposed to either bivalirudin or heparin. In a subset of patients enrolled in UnitedHealth for at least 90 days before hospitalization, additional confounders were assessed from healthcare claims, including comorbidities, prior medication use, and service use intensity. Diagnostics for each method were evaluated, and methods were compared with respect to the estimates and confidence intervals of treatment effects on repeat PCI, bleeding, and in-hospital death. RESULTS Of 210,268 patients in the hospital-based cohort, 3240 (1.5 %) had linked healthcare claims. This subset was younger and healthier than the overall study population. The linked subset was too small for complete case evaluation of two of the three outcomes of interest. Multiple imputation and PS calibration did not meaningfully impact treatment effect estimates and associated confidence intervals. CONCLUSIONS Despite more than 98 % missingness on 24 variables, PS calibration and multiple imputation incorporated confounders from healthcare claims without major increases in estimate uncertainty. Additional research is needed to determine the relative bias of these methods.
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Shah R, Rogers KC, Matin K, Askari R, Rao SV. An updated comprehensive meta-analysis of bivalirudin vs heparin use in primary percutaneous coronary intervention. Am Heart J 2016; 171:14-24. [PMID: 26699596 DOI: 10.1016/j.ahj.2015.10.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 10/14/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Despite several randomized controlled trials and meta-analyses, the ideal anticoagulant for patients undergoing primary percutaneous coronary intervention (PCI) remains controversial. We performed an updated meta-analysis including recently reported randomized clinical trials that compare bivalirudin and heparin with or without provisional administration of a glycoprotein IIb/IIIa inhibitor (GPI) for primary PCI. METHODS AND RESULTS Scientific databases and Web sites were searched for randomized clinical trials. Data from 6 trials involving 14,095 patients were included. The pooled risk ratios (RRs) were calculated using random-effects models. Moderator analyses examined the impact of routine use of GPI, radial access, and P2Y12 inhibitors on safety outcomes. At 30 days, patients receiving bivalirudin had rates of major adverse cardiac events similar to those receiving heparin with or without provisional GPI (RR 1.02, 95% CI 0.87-1.19, P = .800), myocardial infarction (RR 1.41, 95% CI 0.94-2.11, P = .089), target vessel revascularization (RR 1.37, 95% CI 0.91-2.04, P = .122), and net adverse clinical events (RR 0.81, 95% CI 0.64-1.01, P = .069). However, bivalirudin use decreased the risk of all-cause mortality (RR 0.81, 95% CI 0.67-0.99, P = .041) and cardiac mortality (RR 0.68, 95% CI 0.51-0.91, P = .009) at 30 days, There were higher rates of acute stent thrombosis (RR 3.31, 95% CI 1.79-6.10, P < .001) in patients receiving bivalirudin. Bivalirudin use also decreased the risk of major bleeding at 30 days by 37% (RR 0.63, 95% CI 0.44-0.90, P = .012), but bleeding risk varied depending on routine GPI use with heparin (RR 0.44, 95% CI 0.23-0.81, P = .009) vs bailout (RR 0.73, 95% CI 0.42-1.25, P = .252), predominantly radial access (RR 0.54, 95% CI 0.25-1.15, P = .114) vs non-radial access (RR 0.60, 95% CI 0.36-0.99, P = .049), and second-generation P2Y12 inhibitor use with bivalirudin (RR 0.70, 95% CI 0.40-1.24, P = .226) vs clopidogrel use (RR 0.39, 95% CI 0.18-0.85, P = .018). CONCLUSIONS In primary PCI, relative to heparin, bivalirudin reduces the risk for all-cause mortality, cardiac mortality, and major bleeding but yields similar rates of major adverse cardiac event and net adverse clinical event at 30 days. However, the benefit of a reduction in bleeding with bivalirudin appears to be modulated by the concurrent administration of second-generation P2Y12 inhibitors with bivalirudin, using radial access, and avoiding routine GPI use with heparin.
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Angeli F, Reboldi G. Enhancing the Benefit of Bivalirudin in Percutaneous Coronary Intervention: Is High Risk of Bleeding the Key? Am J Cardiovasc Drugs 2015; 15:221-4. [PMID: 26088534 DOI: 10.1007/s40256-015-0138-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Fabio Angeli
- Division of Cardiology and Cardiovascular Pathophysiology, Hospital "S.M. della Misericordia", 06132, Perugia, Italy
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Shahzad A, Stables RH. Bivalirudin versus heparin use for patients undergoing PPCI - Authors' reply. Lancet 2015; 385:2045-6. [PMID: 26009226 DOI: 10.1016/s0140-6736(15)60989-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Adeel Shahzad
- Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool L14 3PE, UK.
| | - Rod H Stables
- Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool L14 3PE, UK
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