Heparin is Not Inferior to Bivalirudin in Percutaneous Coronary Intervention-Focusing on the Effect of Glycoprotein IIb/IIIa Inhibitor Use: A Meta-Analysis

Meta-Analysis Comparing Gender-Based Cardiovascular Outcomes of Transradial Versus Transfemoral Access of Percutaneous Coronary Intervention

Transradial (TR) access for percutaneous coronary intervention (PCI) improves outcomes and reduces the risk of major bleeding compared with transfemoral (TF) access. However, data on gender-stratified outcomes based on vascular access are limited. Databases were queried to find relevant articles. Primary outcomes, including major bleeding complications, mortality, and secondary outcome including major adverse cardiovascular events (MACEs), myocardial infarction, and cerebrovascular accidents, were analyzed using a random-effect model to calculate unadjusted odds ratio (OR) of TR-PCI and TF-PCI between the genders. A total of 9 studies comprising 3,889,257 patients (389,580 in the TR arm and 3,499,677 in the TF arm) were included. Males comprised 73% and 67% of the TR and TF arms, respectively. TR-PCI was associated with lower major bleeding (pooled OR 0.51, 95% CI 0.40 to 0.64, p = 0.00; female OR 0.49, 95% CI 0.34 to 0.71, p = 0.00; male OR 0.54, 95% CI 0.40 to 0.73, p = 0.00) and mortality (pooled OR 0.54, 95% CI 0.45 to 0.66, p = 0.00; female OR 0.56, 95% CI 0.44 to 0.71, p = 0.27; male OR 0.54, 95% CI 0.39 to 0.75, p = 0.00) regardless of gender as compared with TF-PCI. Furthermore, TR-PCI also showed lower MACE (pooled OR 0.74, 95% CI 0.66 to 0.84, p = 0.00; female OR 0.64, 95% CI 0.59 to 0.70, p = 0.00; male OR 0.81, 95% CI 0.66 to 0.98, p = 0.00) as compared with TF-PCI in both genders. On analysis of interaction magnitude of the difference of favor of female and male for TR-PCI showed no statistically significant measurable difference. Periprocedural myocardial infarction and cerebrovascular accidents were not statistically different in TR and TF-PCI and were not different based on gender. In conclusion, TR-PCI was associated with a lower risk of major bleeding, mortality, and MACE irrespective of gender. In conclusion, TR-PCI should be the default access.

Reduced periprocedural mortality and bleeding rates of radial approach in ST-segment elevation myocardial infarction. Propensity score analysis of data from the ORPKI Polish National Registry

AIMS

We sought to evaluate bleeding complications and periprocedural outcomes of the radial approach (RA) as compared to the femoral approach (FA) during percutaneous coronary intervention (PCI) in "real-world" patients with ST-segment elevation myocardial infarction (STEMI).

METHODS AND RESULTS

The study group consisted of 22,812 consecutive patients with STEMI treated with PCI and stent implantation between January 2014 and June 2015 in 151 tertiary invasive cardiology centres in Poland (the ORPKI Polish National Registry). Patients treated using the RA and FA were compared using a propensity score analysis to avoid possible selection bias. The analysis was carried out in an "as-treated" manner. The FA was used in 9,334 (40.9%) and the RA in 13,478 (59.1%) patients. After propensity score matching, a higher total amount of contrast (191.8±8.0 vs. 174.8±68.8 ml; p=0.001) and lower radiation doses (1,279.5±1,346.3 vs. 1,182.6±887 mGy; p=0.02) were reported in FA. More access-site-related bleeding complications after both angiography (0.17% vs. 0.02%; p=0.004) and PCI (0.23% vs. 0.09%; p=0.049) were reported in the FA group. Periprocedural death (1.94% vs. 0.93%; p=0.001) was more common after PCI performed with the FA.

CONCLUSIONS

The radial approach was associated with a lower incidence of periprocedural death in STEMI patients as well as a significant reduction of bleeding complications at the access site.

Safety and Effectiveness of Bivalirudin in Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

Recent clinical trials have shown that while bivalirudin exhibits similar efficacy with heparin, it offers several advantages over heparin, such as a better safety profile. We aimed to evaluate the efficacy and safety of bivalirudin use during Percutaneous Coronary Intervention (PCI) in the treatment of angina and acute coronary syndrome (ACS). We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, EMBASE, and Science Direct from January 1980 to January 2016. Randomized controlled trials (RCTs) comparing bivalirudin to heparin during the course of PCI in patients with angina or ACS were included. Outcome measures included all-cause mortality, myocardial infarction, revascularisation, stent thrombosis, stroke, and major bleeding. The selection, quality assessment, and data extraction of the included trials were done independently by four authors, and disagreements were resolved by consensus. Pooled relative risk (RR) estimates and 95% confidence intervals (CIs) were calculated. A total of 12 RCTs involving 44,088 subjects were included. Bivalirudin appeared to be non-superior compared to heparin in reducing all-cause mortality, myocardial infarction, revascularisation, and stroke. Bivalirudin appeared to be related to a higher risk of stent thrombosis when compared to heparin plus provisional use of a glycoprotein IIb/IIIa inhibitor (GPI) at day 30 (RR 1.94 [1.16, 3.24] p < 0.01). Overall, bivalirudin-based regimens present a lesser risk of major bleeding (RR 0.56 [0.44–0.71] p < 0.001), and Thrombolysis In Myocardial Infarction (TIMI) major bleeding (RR 0.56 [0.43–0.73]) compared with heparin-based regimens either with provisional or routine use of a GPI. However, the magnitude of TIMI major bleeding effect varied greatly (p < 0.001), depending on whether a GPI was provisionally used (RR 0.42 [0.34–0.52] p < 0.001) or routinely used (RR 0.60 [0.43 –0.83] p < 0.001), in the heparin arm. This meta-analysis demonstrated that bivalirudin is associated with a lower risk of major bleeding, but a higher risk of stent thrombosis compared to heparin.

Gender Disparity in the Safety and Efficacy of Radial and Femoral Access for Coronary Intervention: A Systematic Review and Meta-Analysis

Our aim was to investigate the gender disparity in the safety and efficacy of transradial percutaneous coronary intervention (PCI; TRI) and transfemoral PCI (TFI) by a meta-analysis. MEDLINE, Embase, and CENTRAL were searched to identify studies on vascular access with sex-specific events available or studies on sex difference with the events reported by vascular access. Fifteen studies involving 3 921 848 participants were included. Transradial PCI significantly reduced the risk of bleeding complications in both sexes (TRI-versus-TFI odds ratio [OR]: 0.37 in females vs 0.47 in males) and major adverse cardiac events (MACE) in females (OR: 0.70, P < .001) but not in males (OR: 0.83, P = .15) compared to TFI. Transradial PCI diminished the sex difference in the incidence of bleeding complications (female-versus-male OR: 1.82 with TRI vs 2.39 with TFI; interaction P = .01) and MACE (female-versus-male OR: 1.21 with TRI vs 1.41 with TFI; interaction P = .003) compared to TFI. Females were associated with higher crossover rate in the TRI subgroup but not in the TFI subgroup (interaction P = .05). In conclusion, TRI may improve the safety and efficacy of outcomes in both sexes and be an effective means to cut down the gender difference in prognosis.