Bivalirudin during Primary PCI in Acute Myocardial Infarction

Abstract

ResultsAnticoagulation with bivalirudin alone, as compared with heparin plus glycoprotein IIb/IIIa inhibitors, resulted in a reduced 30-day rate of net adverse clinical events (9.2% vs. 12.1%; relative risk, 0.76; 95% confidence interval [CI] 0.63 to 0.92; P = 0.005), owing to a lower rate of major bleeding (4.9% vs. 8.3%; relative risk, 0.60; 95% CI, 0.46 to 0.77; P<0.001). There was an increased risk of acute stent thrombosis within 24 hours in the bivalirudin group, but no significant increase was present by 30 days. Treatment with bivalirudin alone, as compared with heparin plus glycoprotein IIb/IIIa inhibitors, resulted in significantly lower 30-day rates of death from cardiac causes (1.8% vs. 2.9%; relative risk, 0.62; 95% CI, 0.40 to 0.95; P = 0.03) and death from all causes (2.1% vs. 3.1%; relative risk, 0.66; 95% CI, 0.44 to 1.00; P = 0.047). ConclusionsIn patients with ST-segment elevation myocardial infarction who are undergoing primary PCI, anticoagulation with bivalirudin alone, as compared with heparin plus glycoprotein IIb/IIIa inhibitors, results in significantly reduced 30-day rates of major bleeding and net adverse clinical events. (ClinicalTrials.gov number, NCT00433966.)

Efficacy and Safety of Unfractionated Heparin Plus Glycoprotein IIb/IIIa Inhibitors During Revascularization for an Acute Coronary Syndrome: A Meta‐Analysis of Randomized Trials Performed With Stents and Thienopyridines

“…The ACUITY and HORIZONS AMI trials were excluded because these open label trials included a bivalirudin-based strategy. 42,43 Lastly, several trials used a higher dose of unfractionated heparin in the control arm than the GPI arm. This difference might have diminished the relative efficacy of GPIs and masked any increased tendency toward bleeding.…”

Acute Coronary Syndrome: Focus on Antiplatelet Therapy

“…The recently published UK HEAT-PPCI trial showed that heparin led to a lower incidence of ischemic events and a similar incidence of bleeding compared with bivalirudin, suggesting that heparin might be a more costeffective treatment on the basis of these results and its lower cost. 37 In addition to a significant reaction to its delayed consent strategy, the trial has generated much debate in the medical community because of the difference in results compared with previous trials of bivalirudin versus heparin, [38][39][40] although interestingly, a subsequent US study 41 also yielded similar results. It is not clear whether the current debate will influence the next update to the STEMI guidelines, although it is important for all health care professionals treating cardiology patients to be aware of the potential implications with respect to clinical practice as the discussions and investigations will no doubt continue.…”

More, More, More: Reducing Thrombosis in Acute Coronary Syndromes Beyond Dual Antiplatelet Therapy—Current Data and Future Directions

“…To attenuate the risk of future thrombotic events, patients with ACS are treated with dual antiplatelet therapy (DAPT), namely, the combination of aspirin with a P2Y 12 inhibitor, such as clopidogrel, ticagrelor, or prasugrel. Despite DAPT, some ≈10% of ACS patients experience recurrent major adverse cardiovascular events over the subsequent 30 days,2 driving the quest for more effective inhibition of thrombotic pathways. In this review, we provide an overview of studies to date and those ongoing that aim to deliver more effective combinations of antithrombotic agents to patients with recent ACS.…”