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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
Author(s) -
Shah Rahman,
Matin Khalid,
Rogers Kelly C.,
Rao Sunil V.
Publication year - 2017
Publication title -
catheterization and cardiovascular interventions
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.988
H-Index - 116
eISSN - 1522-726X
pISSN - 1522-1946
DOI - 10.1002/ccd.26859
Subject(s) - bivalirudin , medicine , conventional pci , percutaneous coronary intervention , randomized controlled trial , myocardial infarction , adverse effect , subgroup analysis , meta analysis , cardiology
Objective To compare the efficacies of various post‐percutaneous coronary intervenetion (PCI) bivalirudin doses on net adverse clinical events (NACEs) and mortality. Background In primary PCI, lower risk of bleeding with bivalirudin (vs. unfractionated heparin [UFH]) is counterbalanced by an increased risk of acute stent thrombosis (ST). Several randomized clinical trials (RCTs) and a recent meta‐analysis suggest that acute ST risk may be eliminated without compromising the bleeding benefit, but only if the full dose, not a low dose, of bivalirudin is continued post‐PCI. However, it is not known whether this improved risk leads to lower rates of NACEs and mortality. Methods Scientific databases and Web sites were searched for RCTs. Trials were included if study patients were undergoing primary PCI for acute ST‐segment elevation myocardial infarction and were randomly assigned to bivalirudin or UFH treatment. The bivalirudin arm was divided based on post‐PCI bivalirudin dosage: The Biv‐Full group received 1.75 mg/kg/h, the Biv‐Low group, 0.25 mg/kg/h, and the Biv‐No group, none. Results Six RCTs involving 16,842 patients were found. In pairwise meta‐analysis, bivalirudin improved 30‐day all‐cause mortality by 35% and cardiac mortality by 32%, but did not yield a NACE rate better than that achieved with UFH. Subgroup analysis showed the Biv‐Full group had a 46% lower NACE rate and 47% lower all‐cause mortality than UFH. These effects were not seen in the other two groups. Network meta‐analysis yielded similar results. At treatment ranking, the Biv‐Full group yielded the best treatment efficacy. Conclusions In primary PCI, full‐dose bivalirudin infusion for 3‐4 hr after PCI appeared to improve NACE rates compared to UFH. It also seemed to be the most effective strategy for improving cardiac mortality and all‐cause mortality. © 2016 Wiley Periodicals, Inc.