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Safety and efficacy of switching from unfractionated heparin to bivalirudin during primary percutaneous coronary intervention
Author(s) -
Shah Rahman,
Jovin Ion S.,
Chaudhry Amina,
Haji Showkat A.,
Askari Raza,
Dennis Mallie M.,
Berzingi Chalak,
Rao Sunil V.
Publication year - 2019
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.27828
Subject(s) - bivalirudin , medicine , percutaneous coronary intervention , heparin , cardiology , heparin induced thrombocytopenia , myocardial infarction
Objectives To evaluate the safety and efficacy of switching to bivalirudin during primary percutaneous coronary intervention (PCI) for patients who received preprocedure unfractionated heparin (UFH). Background Current guidelines favor bivalirudin for primary PCI in patients at high risk of bleeding, particularly when femoral access is used. However, patients with ST‐segment elevation myocardial infarction frequently receive UFH before arrival in the catheterization laboratory. Methods Scientific databases and websites were searched for randomized controlled trials. Patients were divided into those who received heparin with or without glycoprotein IIb / IIIa inhibitors (heparin group); those switched to bivalirudin during primary PCI from preprocedure UFH (switch group); and those who received bivalirudin without preprocedure UFH (Biv‐alone group). Both traditional pairwise meta‐analyses using moderator analyses and network meta‐analyses using mixed‐treatment comparison models were performed. Results Data from five trials including13,547 patients were analyzed. In mixed‐comparison models, switching to bivalirudin during primary PCI was associated with lower rates for all‐cause mortality and major adverse cardiovascular events (MACEs) compared to the other strategies. Rates for all‐cause mortality, MACEs, and net adverse clinical events (NACEs) were similar for the heparin and Biv‐alone groups. Switching strategies was also associated with lower major bleeding rates compared to heparin alone. Similarly, in a standard pairwise model, both the switch and Biv‐alone groups were associated with decreased bleeding risk compared to the heparin group. However, only the switch strategy was associated with decreased all‐cause mortality (RR, 0.47; 95% CI, 0.30–0.75; P = 0.001), MACE (RR, 0.67; 95% CI, 0.49–0.91; P = 0.012), and NACE (RR, 0.61; 95% CI, 0.41–0.92; P = 0.019) compared with heparin alone. Conclusions During primary PCI, use of bivalirudin for those receiving preprocedure UFH was associated decreased rates for major bleeding, NACEs, MACEs, and all‐cause mortality compared to heparin +/− GPI. This strategy was also associated with decreased rates for MACEs and all‐cause mortality compared to bivalirudin alone without preprocedure UFH.