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Al-Abdouh A, Mhanna M, Jabri A, Madanat L, Alhuneafat L, Mostafa MR, Kundu A, Gupta V. Bivalirudin versus unfractionated heparin in patients with myocardial infarction undergoing percutaneous coronary intervention: A systematic review and meta-analysis of randomized controlled trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 61:52-61. [PMID: 37872022 DOI: 10.1016/j.carrev.2023.10.014] [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: 07/13/2023] [Revised: 10/17/2023] [Accepted: 10/17/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Bivalirudin is an alternative accepted therapy to unfractionated heparin for patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI). We aimed in this meta-analysis to compare bivalirudin versus unfractionated heparin in patients with MI undergoing PCI. METHODS We have screened PubMed/MEDLINE, Cochrane Library, and ClinicalTrials.gov (inception through January 8th, 2023) for randomized controlled trials (RCTs) evaluating bivalirudin versus unfractionated heparin in patients with MI undergoing PCI. The DerSimonian and Laird method was used for estimation of tau2 to calculate the risk ratio (RR) and 95 % confidence interval (CI). RESULTS Ten RCTs with a total of 40,069 participants were included in our analysis. Bivalirudin as compared with unfractionated heparin was associated with significant decrease in major bleeding (RR 0.64 [0.52 to 0.79]; p < 0.01; I2 = 69 %) and cardiovascular mortality (RR 0.79 [0.67 to 0.92]; p < 0.01; I2 = 0 %). There was no significant difference between bivalirudin and unfractionated heparin groups in terms of major adverse cardiovascular events (RR 1.02 [0.91 to 1.14]; p = 0.73; I2 = 52 %), all-cause mortality (RR 0.89 [0.77 to 1.04]; p = 0.15; I2 = 23 %), MI (RR 1.02 [0.87 to 1.19]; p = 0.80; I2 = 36 %), stent thrombosis (RR 1.12 [0.52 to 2.40]; p = 0.77; I2 = 82 %), or stroke (RR 0.97 [0.73 to 1.29]; p = 0.85; I2 = 0 %). CONCLUSION Our meta-analysis suggests that bivalirudin compared with unfractionated heparin in patients with MI undergoing PCI was associated with lower rates of major bleeding and cardiovascular mortality without a significant difference in major adverse cardiovascular events, all-cause mortality, MI, stroke, or stent thrombosis.
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Affiliation(s)
| | - Mohammed Mhanna
- Department of Cardiovascular Medicine, University of Iowa, IA, USA
| | - Ahmad Jabri
- Department of Cardiology, Case Western University (Metrohealth), Cleveland, OH, USA
| | - Luai Madanat
- Department of Medicine, Beaumont Hospital, Detroid, MI, USA
| | - Laith Alhuneafat
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | | | - Amartya Kundu
- Division of Cardiology (Gill Kentucky), University of Kentucky, Lexington, KY, USA
| | - Vedant Gupta
- Division of Cardiology (Gill Kentucky), University of Kentucky, Lexington, KY, USA
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Venetsanos D, Lawesson SS, James S, Koul S, Erlinge D, Swahn E, Alfredsson J. Bivalirudin versus heparin with primary percutaneous coronary intervention. Am Heart J 2018; 201:9-16. [PMID: 29910059 DOI: 10.1016/j.ahj.2018.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 03/21/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Optimal adjunctive therapy in ST-segment elevation myocardial infarction (STEMI) patients treated with primary PCI (PPCI) remains a matter of debate. Our aim was to compare the efficacy and safety of bivalirudin to unfractionated heparin (UFH), with or without glycoprotein IIb/IIIa inhibitors (GPI) in a large real-world population, using data from the Swedish national registry, SWEDEHEART. METHOD From 2008 to 2014 we identified 23,800 STEMI patients presenting within 12 hours from symptom onset treated with PPCI and UFH ± GPI or bivalirudin±GPI. Primary outcomes included 30-day all-cause mortality and major in-hospital bleeding. Multivariable regression models and propensity score modelling were utilized to study adjusted association between treatment and outcome. RESULTS Treatment with UFH ± GPI was associated with similar risk of 30-day mortality compared to bivalirudin±GPI (5.3% vs 5.5%, adjusted HR 0.94; 95% CI 0.82-1.07). The adjusted risk for 1-year mortality, 30-day and 1-year stent thrombosis and re-infarction did not differ significantly between UFH ± GPI and bivalirudin±GPI. In contrast, treatment with UFH ± GPI was associated with a significant higher risk of major in-hospital bleeding (adjusted OR 1.62; 95% CI 1.30-2.03). When including GPI use in the multivariable analysis, the difference was attenuated and no longer significant (adjusted OR 1.25; 95% CI 0.92-1.70). CONCLUSION Bivalirudin±GPI was associated with significantly lower risk for major inhospital bleeding but no significant difference in 30-day or one year mortality, stent thrombosis or re-infarction compared with UFH ± GPI. The bleeding reduction associated with bivalirudin could be explained by the greater GPI use with UFH.
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Affiliation(s)
- Dimitrios Venetsanos
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Sofia Sederholm Lawesson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Stefan James
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Eva Swahn
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Joakim Alfredsson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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Bader Y, Kimmelstiel C. Thrombin inhibition during PCI in heart failure patients. Catheter Cardiovasc Interv 2016; 87:374-5. [PMID: 26919336 DOI: 10.1002/ccd.26438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 01/09/2016] [Indexed: 11/11/2022]
Abstract
In this retrospective analysis, CHF patients undergoing PCI had a decrease in mortality, bleeding, and transfusion as well as decreased length of stay and hospital cost when bivalirudin was used when compared to heparin. This study suggests bivalirudin may be the preferred anticoagulant for patients with CHF undergoing PCI. Confirmation of these data might entail analysis of patient-level, pooled data from randomized controlled trials comparing bivalirudin to heparin in PCI patients with pre-existing CHF.
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Affiliation(s)
- Yusuf Bader
- Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Carey Kimmelstiel
- Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
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Kimmelstiel C, Pinto D, Aronow HD, Weintraub AR, Dangas G, Fan W, Prats J, Deliargyris EN, Katzen BT. Bivalirudin Is Associated With Improved In-Hospital Outcomes Compared With Heparin in Percutaneous Vascular Interventions. Circ Cardiovasc Interv 2016; 9:e002823. [DOI: 10.1161/circinterventions.115.002823] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Peripheral vascular interventions are increasingly preferred for the treatment of patients with symptomatic peripheral arterial disease because they are associated with similar clinical outcomes and lower morbidity than open surgical procedures. The objective of this study was to assess the comparative effectiveness of procedural anticoagulation with bivalirudin compared with unfractionated heparin in patients undergoing peripheral vascular interventions.
Methods and Results—
This was a retrospective, observational study using the Premier Hospital administrative database. We examined 23 934 consecutive patients undergoing lower extremity peripheral vascular interventions between January 2008 and December 2012 who were treated with either bivalirudin or unfractionated heparin. In-hospital end points included death, myocardial infarction, transfusion, stroke, amputation, and the composite end points of major adverse cardiovascular events, and net adverse clinical events. Propensity score matching was performed to control for baseline imbalances and yielded 3649 matched pairs. After propensity score matching, patients treated with bivalirudin had lower in-hospital event rates with significantly lower mortality (odds ratio, 0.40;
P
=0.017), need for blood product transfusion (odds ratio, 0.74;
P
=0.009), major adverse cardiovascular events (odds ratio, 0.64;
P
=0.003), and net adverse clinical events (odds ratio, 0.72;
P
<0.001). These associations were observed consistently across clinically relevant subgroups.
Conclusions—
In patients undergoing peripheral vascular interventions, procedural anticoagulation with bivalirudin may result in more favorable in-hospital outcomes compared with unfractionated heparin, the current standard of care. These observations will require prospective confirmation in a randomized, controlled trial.
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Affiliation(s)
- Carey Kimmelstiel
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - Duane Pinto
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - Herbert D. Aronow
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - Andrew R. Weintraub
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - George Dangas
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - Weihong Fan
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - Jayne Prats
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - Efthymios N. Deliargyris
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
| | - Barry T. Katzen
- From the Cardiac Catheterization Laboratory, Division of Cardiology, Tufts Medical Center, Boston, MA (C.K., A.W.); Beth Israel Deaconess Medical Center, Boston, MA (D.P.); Michigan Heart and Vascular Institute, Ann Arbor (H.D.A.); Icahn School of Medicine at Mount Sinai, New York (G.D.); The Medicines Company, Parsippany, NJ (W.F., J.P., E.N.D.); and Miami Cardiac and Vascular Institute, FL (B.T.K.)
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