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Cross B, Turner RM, Zhang JE, Pirmohamed M. Being precise with anticoagulation to reduce adverse drug reactions: are we there yet? THE PHARMACOGENOMICS JOURNAL 2024; 24:7. [PMID: 38443337 PMCID: PMC10914631 DOI: 10.1038/s41397-024-00329-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/11/2024] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
Anticoagulants are potent therapeutics widely used in medical and surgical settings, and the amount spent on anticoagulation is rising. Although warfarin remains a widely prescribed oral anticoagulant, prescriptions of direct oral anticoagulants (DOACs) have increased rapidly. Heparin-based parenteral anticoagulants include both unfractionated and low molecular weight heparins (LMWHs). In clinical practice, anticoagulants are generally well tolerated, although interindividual variability in response is apparent. This variability in anticoagulant response can lead to serious incident thrombosis, haemorrhage and off-target adverse reactions such as heparin-induced thrombocytopaenia (HIT). This review seeks to highlight the genetic, environmental and clinical factors associated with variability in anticoagulant response, and review the current evidence base for tailoring the drug, dose, and/or monitoring decisions to identified patient subgroups to improve anticoagulant safety. Areas that would benefit from further research are also identified. Validated variants in VKORC1, CYP2C9 and CYP4F2 constitute biomarkers for differential warfarin response and genotype-informed warfarin dosing has been shown to reduce adverse clinical events. Polymorphisms in CES1 appear relevant to dabigatran exposure but the genetic studies focusing on clinical outcomes such as bleeding are sparse. The influence of body weight on LMWH response merits further attention, as does the relationship between anti-Xa levels and clinical outcomes. Ultimately, safe and effective anticoagulation requires both a deeper parsing of factors contributing to variable response, and further prospective studies to determine optimal therapeutic strategies in identified higher risk subgroups.
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Affiliation(s)
- Benjamin Cross
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Richard M Turner
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
- GSK, Stevenage, Hertfordshire, SG1 2NY, UK
| | - J Eunice Zhang
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK.
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Bikdeli B, Erlinge D, Valgimigli M, Kastrati A, Han Y, Steg PG, Stables RH, Mehran R, James SK, Frigoli E, Goldstein P, Li Y, Shahzad A, Schüpke S, Mehdipoor G, Chen S, Redfors B, Crowley A, Zhou Z, Stone GW. Bivalirudin Versus Heparin During PCI in NSTEMI: Individual Patient Data Meta-Analysis of Large Randomized Trials. Circulation 2023; 148:1207-1219. [PMID: 37746717 DOI: 10.1161/circulationaha.123.063946] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND The benefit:risk profile of bivalirudin versus heparin anticoagulation in patients with non-ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI) is uncertain. Study-level meta-analyses lack granularity to provide conclusive answers. We sought to compare the outcomes of bivalirudin and heparin in patients with non-ST-segment-elevation myocardial infarction undergoing PCI. METHODS We performed an individual patient data meta-analysis of patients with non-ST-segment-elevation myocardial infarction in all 5 trials that randomized ≥1000 patients with any myocardial infarction undergoing PCI to bivalirudin versus heparin (MATRIX [Minimizing Adverse Hemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox], VALIDATE-SWEDEHEART [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], ISAR-REACT 4 [Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 4], ACUITY [Acute Catheterization and Urgent Intervention Triage Strategy], and BRIGHT [Bivalirudin in Acute Myocardial Infarction vs Heparin and GPI Plus Heparin Trial]). The primary effectiveness and safety end points were 30-day all-cause mortality and serious bleeding. RESULTS A total of 12 155 patients were randomized: 6040 to bivalirudin (52.3% with a post-PCI bivalirudin infusion), and 6115 to heparin (53.2% with planned glycoprotein IIb/IIIa inhibitor use). Thirty-day mortality was not significantly different between bivalirudin and heparin (1.2% versus 1.1%; adjusted odds ratio, 1.24 [95% CI, 0.86-1.79]; P=0.25). Cardiac mortality, reinfarction, and stent thrombosis rates were also not significantly different. Bivalirudin reduced serious bleeding (both access site-related and non-access site-related) compared with heparin (3.3% versus 5.5%; adjusted odds ratio, 0.59; 95% CI, 0.48-0.72; P<0.0001). Outcomes were consistent regardless of use of a post-PCI bivalirudin infusion or routine lycoprotein IIb/IIIa inhibitor use with heparin and during 1-year follow-up. CONCLUSIONS In patients with non-ST-segment-elevation myocardial infarction undergoing PCI, procedural anticoagulation with bivalirudin and heparin did not result in significantly different rates of mortality or ischemic events, including stent thrombosis and reinfarction. Bivalirudin reduced serious bleeding compared with heparin arising both from the access site and nonaccess sites.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division (B.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Thrombosis Research Group (B.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Yale-New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT (B.B.)
| | | | - Marco Valgimigli
- Bern University Hospital, University of Bern, Switzerland (M.V., E.F.)
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany (A.K., S.S.)
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (A.K., S.S.)
| | - Yaling Han
- General Hospital of Northern Theater Command, Shenyang, China (Y.H., Y.L.)
| | - Philippe Gabriel Steg
- Université Paris-Cité, French Alliance for Cardiovascular Trials, L'Institut national de la santé et de la recherche médicale U-1148, Assistance Publique - Hôpitaux de Paris, Hôpital Bichat, Paris, France (P.G.S.)
- Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.)
| | - Rod H Stables
- Liverpool Heart and Chest Hospital, United Kingdom (R.H.S., A.S.)
- University of Liverpool, United Kingdom (R.H.S., A.S.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
- Cardiovascular Research Foundation, New York, NY (R.M., Z.Z.)
| | | | - Enrico Frigoli
- Bern University Hospital, University of Bern, Switzerland (M.V., E.F.)
| | | | - Yi Li
- General Hospital of Northern Theater Command, Shenyang, China (Y.H., Y.L.)
| | - Adeel Shahzad
- Liverpool Heart and Chest Hospital, United Kingdom (R.H.S., A.S.)
- University of Liverpool, United Kingdom (R.H.S., A.S.)
| | - Stefanie Schüpke
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany (A.K., S.S.)
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (A.K., S.S.)
| | - Ghazaleh Mehdipoor
- Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center, Bronx, NY (G.M.)
| | - Shmuel Chen
- Weill-Cornell Cornell Medical Center/ New York-Presbyterian Hospital, New York, NY (S.C.)
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.)
| | | | - Zhipeng Zhou
- Cardiovascular Research Foundation, New York, NY (R.M., Z.Z.)
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
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Liu YB, Zhou XC, Liu Y, Zhang L, Zhou Y, Xu X, Zheng C, Zhao ZY, Wu CT, Jin JD. Inhibitory role of recombinant neorudin on canine coronary artery thrombosis. Pharmacol Res Perspect 2022; 10:e00956. [PMID: 35505637 PMCID: PMC9065819 DOI: 10.1002/prp2.956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 04/17/2022] [Indexed: 11/26/2022] Open
Abstract
The anticoagulant application is an effective treatment modality for cardiovascular diseases such as coronary heart disease, unstable angina pectoris, and myocardial infarction. In this study, the antithrombotic effect of recombinant neorudin (EPR‐hirudin, EH) was evaluated using a canine model of coronary artery thrombosis. A canine model with platelet thrombosis in the left circumferent branch of the coronary artery was designed using Folt's method, and the anti‐thrombus activity of EH was investigated. Femoral administration of EH intravenously had a significant dose‐dependent inhibitory effect on canine coronary artery thrombosis and the effective rates were 66.7% (p < .05), 83.3% (p < .05), and 100% (p < .01) after injection of 0.3, 1.0, and 3.0 mg/kg EH, respectively. Furthermore, EH demonstrated lower bleeding, with shorter bleeding time and less bleeding loss than low molecular weight heparin (LMWH). Under the similar effect intensity of EH and LMWH (85 IU/kg), the bleeding time of the EH group at 30 min was shorter, and the blood loss at 30–120 min was less than that of LMWH (p < .05 and p < .05–.001, respectively). EH had a significant dose‐dependent inhibitory effect in the dose range of 0.3–3.0 mg/kg on the coronary artery thrombosis and lower bleeding side effects than LMWH with a similar antithrombosis effect.
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Affiliation(s)
- Yu-Bin Liu
- Beijing Institute of Radiation Medicine, Beijing, China
| | | | - Yun Liu
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Lin Zhang
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Ying Zhou
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Xiao Xu
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Can Zheng
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Zhuan-You Zhao
- Center for Pharmacodynamic Research, Tianjin Institute of Pharmaceutical Research, Tianjin, China
| | - Chu-Tse Wu
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Ji-de Jin
- Beijing Institute of Radiation Medicine, Beijing, China
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Jia S, Liu Y, Yuan J. Evidence in Guidelines for Treatment of Coronary Artery Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1177:37-73. [PMID: 32246443 DOI: 10.1007/978-981-15-2517-9_2] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In this chapter, we focus on evidences in current guidelines for treatment of coronary artery disease (CAD). In Part 1, diet and lifestyle management is discussed, which plays an important role in CAD risk control, including forming healthy dietary pattern, maintaining proper body weight, physical exercise, smoking cessation, and so on. Part 2 elaborated on revascularization strategies and medical treatments in patients presenting with acute coronary syndrome (ACS), including specific AHA and ESC guidelines on ST elevation myocardial infarction (STEMI) and non-ST elevation ACS (NSTE-ACS). Part 3 discussed chronic stable coronary artery disease (SCAD), the treatment objective of which is a combination of both symptomatic and prognostic improvement. Yet many of the recommendations for SCAD are expert-based rather than evidence-based. Initial medical treatment is safe and beneficial for most patients. While cumulating studies have focused on optimizing pharmacological therapy (referring to nitrates, beta-blockers, calcium channel blockers, antiplatelet agents, ACEI/ARB, statins, etc.), education, habitual modification, and social support matters a lot for reducing cardiac morbidity and mortality. Patients with moderate-to-severe symptoms and complex lesions should be considered for revascularization. But practical management of revascularization shall take individual characteristics, preference, and compliance into consideration as well.
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Affiliation(s)
- Sida Jia
- Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue Liu
- Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinqing Yuan
- Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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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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Chaudry HI, Curran TB, Andrus BW, Conley SM, DeVries JT. Bivalirudin versus heparin, without glycoprotein inhibition, in percutaneous coronary intervention: A comparison of ischemic and hemorrhagic outcomes over 10years. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 19:338-342. [PMID: 29055661 DOI: 10.1016/j.carrev.2017.09.003] [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: 06/20/2017] [Revised: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The choice of antithrombotic agent used during percutaneous coronary intervention (PCI) is controversial. While earlier studies suggested a reduction in bleeding events with bivalirudin, these studies were confounded by the concomitant use of glycoprotein IIbIIIa inhibitors (GPI) in the heparin group. More recent studies have challenged the superiority of bivalirudin, pointing to an increased risk of stent thrombosis. Real-world data remains limited. METHODS We queried our institutional catheterization laboratory database for all PCI cases performed between January 2003 and December 2012 using only heparin or only bivalirudin (no use of GPI). We collected data on relevant patient and procedural characteristics and compared both efficacy and safety outcomes. We adjusted for baseline differences using coarsened exacting matching. RESULTS 8061 cases met our inclusion criteria. Of these, 34.9% were performed with heparin alone and 65.1% with bivalirudin. After adjusting for baseline differences, we found that those patients receiving heparin had a slightly lower risk of post-procedural abrupt vessel closure (0.1% vs 0.5%). All other outcomes favored bivalirudin including procedural success (97.2% vs 95.5%), transfusion within 72h (2.2% vs 4.8%), retroperitoneal bleeding (0.1% vs 0.8%), and all-cause mortality (0.9% vs 1.9%). Subgroup analysis suggested that outcomes were different only in non-elective cases and non STEMI cases. CONCLUSION Heparin appears to offer the advantage of slightly reduced risk of abrupt vessel closure post-procedure but at the cost of increased hemorrhagic complications and all-cause mortality. This difference in outcomes may be limited to non-elective and non STEMI cases with femoral access.
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Affiliation(s)
- Hannah I Chaudry
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States; Giesel School of Medicine at Dartmouth, Hanover, NH, United States.
| | | | - Bruce W Andrus
- Giesel School of Medicine at Dartmouth, Hanover, NH, United States; Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Sheila M Conley
- Giesel School of Medicine at Dartmouth, Hanover, NH, United States; Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - James T DeVries
- Giesel School of Medicine at Dartmouth, Hanover, NH, United States; Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
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Lupi A, Schaffer A, Rognoni A, Cavallino C, Bongo AS, Cortese B, Jaffe AS, Angiolillo DJ, Porto I. Intracoronary Bivalirudin Bolus in ST-Elevation Myocardial Infarction Patients Treated with Primary Angioplasty: Theoretical Bases, Clinical Experience, and Future Applications. Am J Cardiovasc Drugs 2016; 16:391-397. [PMID: 27541144 DOI: 10.1007/s40256-016-0186-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Intracoronary thrombus is a common finding in acute coronary syndromes and often correlates with adverse prognosis and complications during percutaneous coronary interventions (PCIs). Bivalirudin, a direct thrombin inhibitor, is one of the recommended antithrombotic treatments for PCI in ST-elevation myocardial infarction (STEMI). The intracoronary administration of a bivalirudin loading dose, even if off-label, offers theoretical advantages over the standard intravenous route, providing a very high drug concentration in the infarct-related artery without increasing the total dose of the drug administered. After the description in case reports of such an approach, a larger scale experience was recently reported in a large cohort of patients with STEMI treated during primary PCI with a bivalirudin intracoronary loading dose followed by the standard intravenous maintenance infusion. As a control group, a propensity score-matched cohort of patients undergoing primary PCI treated with intravenous bivalirudin in the same institution was selected. Compared with the intravenous bolus, the intracoronary administration of bivalirudin was associated with improved ST-segment resolution, lower post-procedural peak CK-MB levels, and better Thrombolysis in Myocardial Infarction (TIMI) frame count values, without difference in bleeding rates. Thus, this new promising antithrombotic strategy, based on the intracoronary administration of a bivalirudin loading dose during primary PCI, appeared safe, improved myocardial reperfusion, and mitigated enzymatic myocardial infarct size compared with the standard intravenous protocol. Randomized trials are warranted to confirm these results and evaluate the possible long-term clinical benefits.
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Affiliation(s)
- Alessandro Lupi
- Cardiologia II, AOU Maggiore della Carità, C.so Mazzini 18, 28100, Novara, Italy.
- Cardiology Division, ASL VCO, Domodossola, Italy.
| | - Alon Schaffer
- Cardiologia II, AOU Maggiore della Carità, C.so Mazzini 18, 28100, Novara, Italy
| | - Andrea Rognoni
- Cardiologia II, AOU Maggiore della Carità, C.so Mazzini 18, 28100, Novara, Italy
| | | | - Angelo S Bongo
- Cardiologia II, AOU Maggiore della Carità, C.so Mazzini 18, 28100, Novara, Italy
| | | | - Allan S Jaffe
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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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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10
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New Approaches to the Role of Thrombin in Acute Coronary Syndromes: Quo Vadis Bivalirudin, a Direct Thrombin Inhibitor? Molecules 2016; 21:284. [PMID: 26927051 PMCID: PMC6273416 DOI: 10.3390/molecules21030284] [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: 12/21/2015] [Revised: 02/20/2016] [Accepted: 02/23/2016] [Indexed: 12/12/2022] Open
Abstract
The pathophysiology of acute coronary syndrome (ACS) involves platelet activation and thrombus formation after the rupture of atherosclerotic plaques. Thrombin is generated at the blood-plaque interface in association with cellular membranes on cells and platelets. Thrombin also amplifies the response to the tissue injury, coagulation and platelet response, so the treatment of ACS is based on the combined use of both antiplatelet (such as aspirin, clopidogrel, prasugrel and ticagrelor) and antithrombotic drugs (unfractionated heparin, enoxaparin, fondaparinux and bivalirudin). Bivalirudin competitively inhibits thrombin with high affinity, a predictable response from its linear pharmacokinetics and short action. However, a present remarkable controversy exists between the latest main Guidelines in Clinical Practice and the key trials evaluating the use of bivalirudin in ACS. The aim of this review is to update the development of bivalirudin, including pharmacological properties, obtained information from clinical trials evaluating efficacy and safety of bivalirudin in ACS; as well as the recommendations of clinical Guidelines.
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