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Oli PR, Shrestha DB, Shtembari J, Gyawali P, Regmi L, Bhandari A, Dhungel S, Mattumpuram J, Pant K, Mungee S. Bivalirudin versus heparin in STEMI after BRIGHT-4 trial: an updated meta-analysis. Coron Artery Dis 2023; 34:562-579. [PMID: 37865864 DOI: 10.1097/mca.0000000000001289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
BACKGROUND The use of bivalirudin-based anticoagulation over heparin-based anticoagulation for coronary percutaneous intervention has been debated for a long time. Multiple trials have shown promising benefits of bivalirudin over heparin therapy with the most recent addition being the BRIGHT-4 trial. We performed a meta-analysis to assess evidence from these trials, focusing on the coronary intervention of the STEMI population. METHODS This meta-analysis was performed based on PRISMA guidelines after registering in PROSPERO (CRD42023394701). Databases were searched for relevant articles published before January 2023. Pertinent data from the included studies were extracted and analyzed using RevMan v5.4. RESULTS Out of 2375 studies evaluated, 13 randomized control trials with 24 360 acute ST-elevation myocardial infarction patients were included for analysis. The bivalirudin-based anticoagulation reduced the net clinical events (OR 0.75, CI 0.61-0.92), major adverse cardiac or cerebral events (OR 0.85, CI 0.74-0.98), any bleeding (OR 0.61, CI 0.45-0.83), major bleeding (OR 0.54, CI 0.39-0.75), all-cause mortality (OR 0.79, CI 0.67-0.92) and cardiac mortality (OR 0.78, CI 0.65-0.93) significantly without increasing the risk of any stent thrombosis (OR 0.92, 95% CI 0.52-1.61), definite stent thrombosis (OR 1.17, 95% CI 0.62-2.22) and acute stent thrombosis (OR 2.06, 95% CI 0.69-6.09) significantly at 30 days. CONCLUSION Based on this meta-analysis, bivalirudin plus a post-PCI high-dose infusion-based anticoagulation during STEMI PCI has significant benefits over heparin therapy for cardiovascular outcomes without a significant increase in the risk of thrombotic outcomes.
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Affiliation(s)
- Prakash Raj Oli
- Department of Internal Medicine, Karnali Province Hospital, Birendranagar, Nepal
| | | | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, Illinois, USA
| | - Pratik Gyawali
- Department of Internal Medicine, Om Saibaba Memorial Hospital, Kathmandu
| | - Laxmi Regmi
- Department of Internal Medicine, Karnali Province Hospital, Birendranagar
| | - Amit Bhandari
- Department of Internal Medicine, Sait Johns Hospital, HSHS Medical Group, Springfield
| | - Swati Dhungel
- Department of Internal Medicine, Division of Cardiovascular Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | - Jishanth Mattumpuram
- Division of Cardiology, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Kailash Pant
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Illinois College of Medicine, OSF Healthcare, Peoria, Illinois, USA
| | - Sudhir Mungee
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Illinois College of Medicine, OSF Healthcare, Peoria, Illinois, USA
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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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Shah R. Impact of bivalirudin with a post-procedure infusion versus heparin-monotherapy on stent thrombosis and cardiovascular mortality. Coron Artery Dis 2023; 34:520-521. [PMID: 37799049 DOI: 10.1097/mca.0000000000001269] [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: 10/07/2023]
Affiliation(s)
- Rahman Shah
- Department of Cardiovascular Medicine, Methodist Le Bonheur Healthcare, University of Tennessee, Memphis, Tennessee, USA
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Galli M, Bernardi M, Ortega-Paz L, Nerla R, D'Amario D, Franchi F, Biondi-Zoccai G, Angiolillo DJ. Bivalirudin in acute coronary syndromes. Expert Rev Cardiovasc Ther 2023; 21:901-911. [PMID: 37919937 DOI: 10.1080/14779072.2023.2273902] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Bivalirudin, a bivalent direct thrombin inhibitor, has been developed to reduce bleeding without any trade-off in thrombotic events in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). AREAS COVERED Despite showing a superior safety profile compared with unfractionated heparin (UFH), bivalirudin is not considered the anticoagulant of choice in ACS patients undergoing PCI, mainly because of an increased rate of acute stent thrombosis (ST) shown by several randomized controlled trials (RCTs), in addition to limited availability in certain countries and increased costs. However, RCTs on bivalirudin have been characterized by several confounding factors hindering the interpretation of its safety and efficacy compared with UFH among the spectrum of ACS patients. Furthermore, a significant body of evidence has demonstrated that the risk of acute ST can be mitigated by a full-dose infusion regimen following PCI, without compromising the favorable safety profile compared to UFH. EXPERT OPINION In light of the increased understanding of the prognostic relevance of bleeding events and the excellent safety profile of bivalirudin, recent trial evidence may allow for this anticoagulant agent to reemerge and have a more prominent role in the management of ACS patients undergoing PCI.
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Affiliation(s)
- Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Marco Bernardi
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Roberto Nerla
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Domenico D'Amario
- Dipartimento Universitario di Medicina Traslazionale, Università Piemonte Orientale, Azienda Ospedaliero-Universitaria Maggiore della Carità di Novara, Novara, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Mediterranea Cardiocentro, Napoli, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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Vergallo R, Patrono C. A BRIGHT outlook for bivalirudin in patients with ST-segment elevation myocardial infarction. Eur Heart J 2023; 44:549-550. [PMID: 36478196 DOI: 10.1093/eurheartj/ehac732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Rocco Vergallo
- Interventional Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6-16132 Genova, Italy
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Viale Benedetto XV, 6-16132 Genova, Italy
| | - Carlo Patrono
- Department of Pharmacology, Catholic University of the Sacred Heart, Largo F. Vito, 8-00168 Rome, Italy
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Li Y, Liang Z, Qin L, Wang M, Wang X, Zhang H, Liu Y, Li Y, Jia Z, Liu L, Zhang H, Luo J, Dong S, Guo J, Zhu H, Li S, Zheng H, Liu L, Wu Y, Zhong Y, Qiu M, Han Y, Stone GW. Bivalirudin plus a high-dose infusion versus heparin monotherapy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: a randomised trial. Lancet 2022; 400:1847-1857. [PMID: 36351459 DOI: 10.1016/s0140-6736(22)01999-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/09/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Previous randomised trials of bivalirudin versus heparin in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) have reported conflicting results, in part because of treatment with different pharmacological regimens. We designed a large-scale trial examining bivalirudin with a post-PCI high-dose infusion compared with heparin alone, the regimens that previous studies have shown to have the best balance of safety and efficacy. METHODS BRIGHT-4 was an investigator-initiated, open-label, randomised controlled trial conducted at 87 clinical centres in 63 cities in China. Patients with STEMI undergoing primary PCI with radial artery access within 48 h of symptom onset who had not received previous fibrinolytic therapy, anticoagulants, or glycoprotein IIb/IIIa inhibitors were randomly assigned (1:1) to receive bivalirudin with a post-PCI high-dose infusion for 2-4 h or unfractionated heparin monotherapy. There was no masking. Glycoprotein IIb/IIIa inhibitor use was reserved for procedural thrombotic complications in both groups. The primary endpoint was a composite of all-cause mortality or Bleeding Academic Research Consortium (BARC) types 3-5 bleeding at 30 days. This trial is registered with ClinicalTrials.gov (NCT03822975), and is ongoing. FINDINGS Between Feb 14, 2019, and April 7, 2022, a total of 6016 patients with STEMI undergoing primary PCI were randomly assigned to receive either bivalirudin plus a high-dose infusion after PCI (n=3009) or unfractionated heparin monotherapy (n=3007). Radial artery access was used in 5593 (93·1%) of 6008 patients. Compared with heparin monotherapy, bivalirudin reduced the 30-day rate of the primary endpoint (132 events [4·39%] in the heparin group vs 92 events [3·06%] in the bivalirudin group; difference, 1·33%, 95% CI 0·38-2·29%; hazard ratio [HR] 0·69, 95% CI 0·53-0·91; p=0·0070). All-cause mortality within 30 days occurred in 118 (3·92%) heparin-assigned patients and in 89 (2·96%) bivalirudin-assigned patients (HR 0·75; 95% CI 0·57-0·99; p=0·0420), and BARC types 3-5 bleeding occurred in 24 (0·80%) heparin-assigned patients and five (0·17%) bivalirudin-assigned patients (HR 0·21; 95% CI 0·08-0·54; p=0·0014). There were no significant differences in the 30-day rates of reinfarction, stroke, or ischaemia-driven target vessel revascularisation between the groups. Within 30 days, stent thrombosis occurred in 11 (0·37%) of bivalirudin-assigned patients and 33 (1·10%) of heparin-assigned patients (p=0·0015). INTERPRETATION In patients with STEMI undergoing primary PCI predominantly with radial artery access, anticoagulation with bivalirudin plus a post-PCI high-dose infusion for 2-4 h significantly reduced the 30-day composite rate of all-cause mortality or BARC types 3-5 major bleeding compared with heparin monotherapy. FUNDING Chinese Society of Cardiology Foundation (CSCF2019A01), and a research grant from Jiangsu Hengrui Pharmaceuticals.
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Affiliation(s)
- Yi Li
- General Hospital of Northern Theater Command, Shenyang, China
| | - Zhenyang Liang
- General Hospital of Northern Theater Command, Shenyang, China
| | - Lei Qin
- Kaifeng Central Hospital, Kaifeng, China
| | - Mian Wang
- West China Hospital of Sichuan University, Chengdu, China
| | | | | | - Yin Liu
- Tianjin Chest Hospital, Tianjin, China
| | - Yan Li
- Tangdu Hospital of Airforce Medical University, Xi'an, China
| | - Zhisheng Jia
- The Fifth People's Hospital of Jinan, Jinan, China
| | - Limin Liu
- The Second Hospital of Shenyang Medical College, Shenyang, China
| | - Hongyan Zhang
- Affiliated Hospital of Qilu Medical University, The People's Hospital of Xintai City, Xintai, China
| | - Jun Luo
- Ganzhou People's Hospital, Ganzhou, China
| | | | - Jincheng Guo
- Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | | | - Shengli Li
- Shangqiu First People's Hospital, Shangqiu, China
| | | | - Lijun Liu
- The First Affiliated Hospital of Anhui University of Science and Technology, Huainan, China
| | - Yanqing Wu
- The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yiming Zhong
- The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Miaohan Qiu
- General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- General Hospital of Northern Theater Command, Shenyang, China.
| | - Gregg W Stone
- Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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A Meta-analysis of Clinical Trials Evaluating the Impact of Bivalirudin-based Anticoagulation for Primary Percutaneous Coronary on Long-Term Mortality. J Cardiovasc Pharmacol 2021; 78:e40-e44. [PMID: 33929388 DOI: 10.1097/fjc.0000000000001029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/16/2021] [Indexed: 01/17/2023]
Abstract
ABSTRACT Bivalirudin and heparin are the principal anticoagulants used during primary percutaneous coronary intervention (PCI) for patients experiencing ST-elevation myocardial infarctions. Based on previous meta-analyses, bivalirudin improves 30-day mortality rates compared with heparin, especially when vascular access is predominantly femoral. However, no meta-analysis has yet reported whether this mortality benefit with bivalirudin persists beyond 30 days. Scientific databases and websites were searched to find randomized controlled trials, and risk ratios (RRs) were calculated using random effect models. Data from 4 trials were analyzed. Compared with heparin ± glycoprotein IIb/IIIa inhibitors, bivalirudin decreased all-cause mortality [RR, 0.81; 95% confidence interval (CI), 0.69-0.94; P = 0.008], cardiac mortality (RR, 0.72; 95% CI, 0.60-0.88; P = 0.001), and net adverse clinical events (RR, 0.83; 95% CI, 0.72-0.97; P = 0.016) at 1 year. In conclusion, a bivalirudin-based anticoagulation strategy during primary percutaneous coronary intervention significantly decreases the 1-year risks for all-cause mortality, cardiac mortality, and net adverse clinical events compared with heparin ± glycoprotein IIb/IIIa inhibitor.
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Garcia-Garcia HM, Picchi A, Sardella G, Adamo M, Frigoli E, Limbruno U, Rigattieri S, Diletti R, Boccuzzi G, Zimarino M, Contarini M, Russo F, Calabro' P, Andò G, Varbella F, Garducci S, Palmieri C, Briguori C, Kuku KO, Rothenbühler M, Karagiannis A, Valgimigli M. Comparison of intra-procedural vs. post-stenting prolonged bivalirudin infusion for residual thrombus burden in patients with ST-segment elevation myocardial infarction undergoing: the MATRIX (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and angioX) OCT study. Eur Heart J Cardiovasc Imaging 2021; 20:1418-1428. [PMID: 30920584 DOI: 10.1093/ehjci/jez040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 02/25/2019] [Indexed: 11/14/2022] Open
Abstract
AIMS To compare prolonged bivalirudin infusion vs. an intra-procedural only bivalirudin infusion administration in subjects with ST-segment elevation myocardial infarction (STEMI) regarding residual stent strut thrombosis. METHODS AND RESULTS Multivessel STEMI patients undergoing primary percutaneous coronary intervention (PPCI) and scheduled for a staged percutaneous coronary intervention (PCI) before hospital discharge were selected among those allocated to either prolonged bivalirudin or intra-procedural only bivalirudin infusion in the MATRIX (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and angioX) Treatment-Duration study. Optical coherence tomography (OCT) of the infarct-related artery was performed at the end of PPCI and 4-5 days thereafter during staged intervention. The predefined endpoint was the percentage difference in the number of stent cross-sections with a thrombotic area >5% at the end of PPCI and at the time of staged PCI (ΔThCS). Between September 2013 and November 2015, 137 were randomized to either intra-procedural only bivalirudin infusion (N = 64) or prolonged bivalirudin (N = 73) at 16 European sites. Mean stent area, minimum lumen area, percentage of malapposed struts, and mean percent thrombotic area were comparable after index or staged PCI. The difference in the proportion of frames with percent thrombotic area >5% (ΔTh > 5%) were -7.7 (-22.1 to 5.1) in the intra-procedural bivalirudin infusion group and -8.8 (-23.1 to 2.6) in the prolonged infusion group (P = 0.994). Time from index to follow-up OCT imaging and the infarct vessel artery did not affect this OCT-based endpoint. CONCLUSION A strategy of prolonged bivalirudin infusion after PPCI did not reduce residual stent strut thrombosis when compared with intra-procedural only bivalirudin infusion administration (funded by The Medicines Company and Terumo; MATRIX ClinicalTrials.gov number, NCT01433627).
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Affiliation(s)
| | | | | | | | - Enrico Frigoli
- Clinical Trials Unit, University of Bern, Bern, Switzerland
| | | | | | - Roberto Diletti
- Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Marco Zimarino
- Università degli Studi "G. d'Annunzio" Chieti e Pescara, Chieti, Italy
| | | | | | - Paolo Calabro'
- Division of Cardiology, Department of Cardiothoracic and Respiratory Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giuseppe Andò
- Azienda Ospedaliera Universitaria G. Martino, Messina, Italy
| | | | - Stefano Garducci
- Unita' Operativa Complessa di Cardiologia ASST di Vimercate (MB), Vimercate, Italy
| | - Cataldo Palmieri
- Institute of Clinical Physiology, C.N.R./G. Monasterio Foundation, Massa, Italy
| | | | | | | | | | - Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University Hospital, Freiburgstrasse 8, Bern, Switzerland
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Zhang Y, Zhang Y, Liu Z, Zhang B, Liu G, Chen K. Bivalirudin versus unfractionated heparin during percutaneous coronary intervention in high-bleeding-risk patients with acute coronary syndrome in contemporary practice. Biomed Pharmacother 2020; 130:110758. [PMID: 34321166 DOI: 10.1016/j.biopha.2020.110758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Bivalirudin, as compared with unfractionated heparin (UFH), has been shown to reduce bleeding complications and supply a better safety profile among low/medium-bleeding-risk patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) in some previous studies. Whether this advantage persists in patients at high risk of bleeding according to contemporary practice characterized by frequent use of radial-artery access and novel P2Y12 inhibitors, and low use of glycoprotein IIb/IIIa inhibitors (GPIs) is unclear. AIM OF THE STUDY This study aimed to assess the efficacy and safety of bivalirudin compared with UFH in high bleeding risk patients with ACS undergoing PCI in current practice. MATERIALS AND METHODS All consecutive high-bleeding-risk patients who underwent PCI for ACS at the First Affiliated Hospital of Zhengzhou University from January to September 2019 were retrospectively analyzed. The 30-day primary outcome was a composite of major bleeding, myocardial infarction, all-cause death, or stroke (net adverse clinical events [NACEs]), and the secondary outcomes at 30 days included a composite of myocardial infarction, stoke, or all-cause death (major adverse cardiovascular events [MACEs]), each component of the primary outcome, target vessel revascularization (TVR) and stent thrombosis (ST). Besides, we assessed angina-related health status at 30 days, the length of hospital stay, and hospitalization costs. A logistic regression model was used to adjust for baseline differences. Consistency of the treatment effect of bivalirudin for NACEs and MACEs compared with UFH was evaluated in 15 prespecified subgroups. RESULTS From January to September 2019, 823 patients (361 treated with bivalirudin and 462 treated with UFH) were enrolled in the study. GPIs, novel P2Y12 inhibitors, and radial approach was used in 5.6 %, 66.1 %, and 89.7 % of the patients, respectively. After adjusting for baseline differences, bivalirudin was associated with significant reduction in NACEs, MACEs, major bleeding, and myocardial infarction at 30 days compared with UFH. The individual endpoints of death, stroke, ST and TVR did not differ significantly between the 2 groups after adjusting for covariates. Furthermore, bivalirudin consistently reduced the rates of NACEs and MACEs in the 15 prespecified subgroups compared with UFH. These benefits of bivalirudin can translate into improved angina-related health status, shorter hospital stays, and lower hospitalization costs. CONCLUSIONS The treatment of bivalirudin showed better efficacy and safety as compared to UFH among patients with ACS undergoing PCI at high risk of bleeding in contemporary practice.
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Affiliation(s)
- Yahao Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Yanghui Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Zhiyu Liu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Bin Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Guizhi Liu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Kui Chen
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
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Post-Procedural Bivalirudin Infusion at Full or Low Regimen in Patients With Acute Coronary Syndrome. J Am Coll Cardiol 2020; 73:758-774. [PMID: 30784669 DOI: 10.1016/j.jacc.2018.12.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/03/2018] [Accepted: 12/10/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND The value of prolonged bivalirudin infusion after percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS) patients with or without ST-segment elevation remains unclear. OBJECTIVES The purpose of this study was to assess efficacy and safety of a full or low post-PCI bivalirudin regimen in ACS patients with or without ST-segment elevation. METHODS The MATRIX program assigned bivalirudin to patients without or with a post-PCI infusion at either a full (1.75 mg/kg/h for ≤4 h) or reduced (0.25 mg/kg/h for ≤6 h) regimen at the operator's discretion. The primary endpoint was the 30-day composite of urgent target-vessel revascularization, definite stent thrombosis, or net adverse clinical events (composite of all-cause death, myocardial infarction, or stroke, or major bleeding). RESULTS Among 3,610 patients assigned to bivalirudin, 1,799 were randomized to receive and 1,811 not to receive a post-PCI bivalirudin infusion. Post-PCI full bivalirudin was administered in 612 (ST-segment elevation myocardial infarction [STEMI], n = 399; non-ST-segment elevation acute coronary syndromes [NSTE-ACS], n = 213), whereas the low-dose regimen was administered in 1,068 (STEMI, n = 519; NSTE-ACS, n = 549) patients. The primary outcome did not differ in STEMI or NSTE-ACS patients who received or did not receive post-PCI bivalirudin. However, full compared with low bivalirudin regimen remained associated with a significant reduction of the primary endpoint after multivariable (rate ratio: 0.21; 95% CI: 0.12 to 0.35; p < 0.001) or propensity score (rate ratio: 0.16; 95% CI: 0.09 to 0.26; p < 0.001) adjustment. Full post-PCI bivalirudin was associated with improved outcomes consistently across ACS types compared with the no post-PCI infusion or heparin groups. CONCLUSIONS In ACS patients with or without ST-segment elevation, the primary endpoint did not differ with or without post-PCI bivalirudin infusion but a post-PCI full dose was associated with improved outcomes when compared with no or low-dose post-PCI infusion or heparin (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX [MATRIX]; NCT01433627).
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Shah R, Naz A. Postprocedure bivalirudin infusion for primary percutaneous coronary intervention. Catheter Cardiovasc Interv 2019; 94:900-901. [PMID: 31241248 DOI: 10.1002/ccd.28377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 06/02/2019] [Accepted: 06/09/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Rahman Shah
- Department of Medicine, Gulf Coast Medical Center, Panama City, Florida
| | - Arshi Naz
- Department of Medicine, Sir Syed College of Medical Sciences, Karachi, Pakistan
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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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Gargiulo G, da Costa BR, Frigoli E, Palmieri C, Nazzaro MS, Falcone C, Liso A, Vigna C, Abate F, Comeglio M, Diletti R, Gabrielli G, Di Lorenzo E, Mazzarotto P, Zimarino M, Moretti C, Colombo A, Penzo C, Pasquetto G, Brugaletta S, Ferrari F, Casu G, Guiducci V, Dellavalle A, Liistro F, Mauro C, van't Hof AW, Omerovic E, Curello S, de la Torre Hernandez JM, De Servi S, Belloni F, Windecker S, Valgimigli M. Impact of sex on comparative outcomes of bivalirudin versus unfractionated heparin in patients with acute coronary syndromes undergoing invasive management: a pre-specified analysis of the MATRIX trial. EUROINTERVENTION 2019; 15:e269-e278. [DOI: 10.4244/eij-d-18-00247] [Citation(s) in RCA: 2] [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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OCT Appraisal of Residual Thrombus Burden in Patients With STEMI Undergoing Intraprocedural Versus Post-Stenting Prolonged Bivalirudin Infusion. JACC Cardiovasc Imaging 2019; 12:934-936. [DOI: 10.1016/j.jcmg.2018.10.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/22/2018] [Accepted: 10/25/2018] [Indexed: 11/24/2022]
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Shah R, Latham SB, Porta JM, Naz A, Matin K, Rao SV. Bivalirudin with a post‐procedure infusion versus heparin monotherapy for the prevention of stent thrombosis. Catheter Cardiovasc Interv 2019; 94:210-215. [DOI: 10.1002/ccd.28065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 12/10/2018] [Accepted: 12/16/2018] [Indexed: 01/23/2023]
Affiliation(s)
- Rahman Shah
- Department of MedicineUniversity of Tennessee, School of Medicine Memphis Tennessee
- Department of CardiologyVeterans Affairs Medical Center Memphis Tennessee
| | - Samuel B. Latham
- Department of MedicineUniversity of Tennessee, School of Medicine Memphis Tennessee
| | - Jennifer M. Porta
- Department of MedicineUniversity of Tennessee, School of Medicine Memphis Tennessee
| | - Arshi Naz
- Department of MedicineSir Syed College of Medical Sciences Karachi Pakistan
| | - Khalid Matin
- Department of MedicineVirginia Commonwealth University Richmond Virginia
| | - Sunil V. Rao
- Department of CardiologyDuke Clinical Research Institute Durham North Carolina
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Elgendy IY, Capodanno D. Heparin versus bivalirudin for percutaneous coronary intervention: has the debate come to an end? J Thorac Dis 2017; 9:4305-4307. [PMID: 29268497 PMCID: PMC5721029 DOI: 10.21037/jtd.2017.10.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 10/09/2017] [Indexed: 08/29/2023]
Affiliation(s)
- Islam Y. Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Davide Capodanno
- Division of Cardiology, Ferrarotto Hospital, University of Catania, Catania, Italy
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Shah R, Matin K, Rogers KC, Rao SV. Effect of post-primary percutaneous coronary intervention bivalirudin infusion on net adverse clinical events and mortality: A comprehensive pairwise and network meta-analysis of randomized controlled trials. Catheter Cardiovasc Interv 2017; 90:196-204. [DOI: 10.1002/ccd.26859] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Rahman Shah
- School of Medicine; Section of Cardiology, University of Tennessee; Memphis TN
- Veterans Affairs Medical Center; Memphis TN
| | - Khalid Matin
- Section of Hematology, Virginia Commonwealth University; Richmond VA
| | - Kelly C. Rogers
- College of Pharmacy; The University of Tennessee; Memphis TN
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Ge J, Yu H, Li J. Acute Coronary Stent Thrombosis in Modern Era: Etiology, Treatment, and Prognosis. Cardiology 2017; 137:246-255. [DOI: 10.1159/000464404] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 02/22/2017] [Indexed: 11/19/2022]
Abstract
Acute stent thrombosis (AST) is a rare but life-threatening complication of coronary artery stenting. AST remains a challenging task for cardiologists, despite the application of modern procedural techniques and dual-antiplatelet therapy strategies as well as improved understanding of the underlying pathophysiology. This review focuses on the prevalence, risk factors, prognosis, multiple potential underlying pathogenesis, knowledge gaps, and recommends diagnosis and individualized management strategies of AST.
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Bivalirudin versus Heparin plus Glycoprotein IIb/IIIa Inhibitors in Women Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials. PLoS One 2017; 12:e0169951. [PMID: 28095453 PMCID: PMC5241007 DOI: 10.1371/journal.pone.0169951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 12/27/2016] [Indexed: 11/19/2022] Open
Abstract
Bivalirudin has been shown to be safe and efficacious compared with heparin plus glycoprotein IIb/IIIa inhibitor (GPI) in patients undergoing percutaneous coronary intervention (PCI). Whether bivalirudin would have the beneficial effects in female patients undergoing PCI remains unknown. We searched the literature for randomized controlled trials that assessed bivalirudin versus heparin plus GPI therapy in female patients undergoing PCI. The primary efficacy end point was major adverse cardiovascular events (MACE) within 30 days. The secondary efficacy end points were 30-day incidence of all-cause mortality, myocardial infarction (MI), urgent/ischemia-driven revascularization of target vessel. The safety end point was major bleeding up to 30 days. A total of 4,501 female patients were included in five randomized trials. No significant difference in MACE emerged between bivalirudin and heparin plus GPI at 30 days (8.15% vs 8.76%, RR 0.94, 95% CI 0.77-1.16, P = .57). There were no significant differences in rates of mortality (1.28% vs 1.91%, RR 0.74, 95% CI 0.45-1.20, P = .22), MI (5.46% vs 5.25%, RR 1.02, 95% CI 0.79-1.32, p = .88), or target vessel revascularization (2.13% vs 1.65%, RR 1.43, 95% CI 0.88-2.30, P = .15). Compared with heparin plus GPI, bivalirudin was associated with a significant reduction in 30-day major bleeding (5.32% vs 9.20%, RR 0.58, 95% CI 0.47-0.72, P < .0001). In conclusion, bivalirudin is associated with a significant reduction in 30-day major bleeding without increased ischemic events compared with heparin plus GPI in female patients undergoing PCI.
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Wang H, Liang Z, Li Y, Li B, Liu J, Hong X, Lu X, Wu J, Zhao W, Liu Q, An J, Li L, Pu F, Ming Q, Han Y. Effect of postprocedural full-dose infusion of bivalirudin on acute stent thrombosis in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: Outcomes in a large real-world population. Cardiovasc Ther 2017; 35. [PMID: 28083915 DOI: 10.1111/1755-5922.12251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/07/2017] [Accepted: 01/02/2017] [Indexed: 11/28/2022] Open
Abstract
AIM This study aimed to evaluate the effect of prolonged full-dose bivalirudin infusion in real-world population with ST-elevation myocardial infarction (STEMI). BACKGROUND Subgroup data as well as meta-analysis from randomized clinical trials have shown the potency of postprocedural full-dose infusion (1.75 mg/kg/h) of bivalirudin on attenuating acute stent thrombosis (ST) after primary percutaneous coronary intervention (PCI). METHODS In this multicenter retrospective observational study, 2047 consecutive STEMI patients treated with bivalirudin during primary PCI were enrolled in 65 Chinese centers between July 2013 and May 2016. The primary outcome was acute ST defined as ARC definite/probable within 24 hours after the index procedure, and the secondary endpoints included total ST, major adverse cardiac or cerebral events (MACCE, defined as death, reinfarction, stroke, and target vessel revascularization), and any bleeding at 30 days. RESULTS Among 2047 STEMI patients, 1123 (54.9%) were treated with postprocedural bivalirudin full-dose infusion (median 120 minutes) while the other 924 (45.1%) received low-dose (0.25 mg/kg/h) or null postprocedural infusion. A total of three acute ST (0.3%) occurred in STEMI patients with none or low-dose prolonged infusion of bivalirudin, but none was observed in those treated with post-PCI full-dose infusion (0.3% vs 0.0%, P=.092). Outcomes on MACCE (2.1% vs 2.7%, P=.402) and total bleeding (2.1% vs 1.4%, P=.217) at 30 days showed no significant difference between the two groups, and no subacute ST was observed. CONCLUSION Post-PCI full-dose bivalirudin infusion is safe and has a trend to protect against acute ST in STEMI patients undergoing primary PCI in real-world settings.
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Affiliation(s)
- Heyang Wang
- General Hospital of Shenyang Military Region, Shenyang, China
| | - Zhenyang Liang
- General Hospital of Shenyang Military Region, Shenyang, China
| | - Yi Li
- General Hospital of Shenyang Military Region, Shenyang, China
| | - Bin Li
- Hainan General Hospital, Haikou, China
| | - Junming Liu
- Xinjiang Corps General Hospital, Urumchi, China
| | - Xueyi Hong
- Beijing Shijingshan Hospital, Beijing, China
| | - Xin Lu
- Fujian Medical University Affiliated First Quanzhou Hospital, Quanzhou, China
| | | | - Wei Zhao
- Tianjin Chest Hospital, Tianjin, China
| | - Qiang Liu
- Shenzhen Sun Yat-sen Cardiovascular Hospital, Shenzhen, China
| | - Jian An
- Shanxi Cardiovascular Hospital, Taiyuan, China
| | - Linfeng Li
- Jiangxi Province People's Hospital, Nanchang, China
| | - Fanli Pu
- Dongying People's Hospital, Dongying, China
| | - Qiang Ming
- Shanghai Tenth People's Hospital, Shanghai, China
| | - Yaling Han
- General Hospital of Shenyang Military Region, Shenyang, China
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Reply. JACC Cardiovasc Interv 2016; 9:1973. [DOI: 10.1016/j.jcin.2016.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 07/14/2016] [Indexed: 11/21/2022]
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Mahmoud AN, Elgendy IY, Bavry AA. The Hidden Players. JACC Cardiovasc Interv 2016; 9:1972. [DOI: 10.1016/j.jcin.2016.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 06/29/2016] [Indexed: 10/21/2022]
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Bivalirudin in Current Practice. JACC Cardiovasc Interv 2016; 9:1321-3. [DOI: 10.1016/j.jcin.2016.05.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 05/23/2016] [Accepted: 05/23/2016] [Indexed: 11/21/2022]
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