Study Compares Anticoagulants in STEMI Patients Receiving Transradial Primary PCI
May 30, 2017—The American College of Cardiology (ACC) announced the publication of a study showing no significant difference in the rate of a composite of death, myocardial infarction, or stroke in patients undergoing transradial primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) who were anticoagulated with bivalirudin versus unfractioned heparin. The study by Ion S. Jovin, MD, et al is available online ahead of print in Journal of the American College of Cardiology: Cardiovascular Interventions.
According to the ACC, the investigators used data from the National Cardiovascular Data Registry CathPCI Registry to examine the records of 67,368 patients from 1,584 sites between 2009 to 2015 with STEMI who underwent primary PCI via radial access. Of these patients, 29,660 received bivalirudin and 37,708 received heparin. The groups did not differ substantially in mean age (60.3 and 60.4 years, respectively) or percentage of men (74.9% and 75%, respectively).
The investigators adjusted for multiple variables, including a propensity score reflecting the probability of receiving bivalirudin to account for patient differences between groups. After these adjustments, the odds ratio of the composite endpoint of death, myocardial infarction, or stroke for bivalirudin versus heparin was not statistically significant (0.95); the odds ratio for acute stent thrombosis was 2.11 for bivalirudin versus heparin. Major bleeding rates were not significantly different.
The investigators suggested that a randomized trial in patients treated exclusively via transradial primary PCI and anticoagulated with bivalirudin versus heparin, as well as a cost-effectiveness analysis comparing heparin versus bivalirudin would help practitioners and hospitals make better decisions regarding anticoagulation in these patients, reported the ACC.
In the ACC press release, Dr. Jovin noted that the study's results are consistent with data from contemporary studies of patients with acute coronary syndrome and STEMI. Dr. Jovin commented, "Our sensitivity analysis provides some insights into direct comparisons of bivalirudin and heparin when GP IIb/IIIa inhibitors are forced out of the equation and suggests that in direct comparison, bivalirudin may have superior outcomes. However, our study showed that in the real world, over a third of the patients with STEMI undergoing transradial PCI who receive heparin and about a fifth of patients who receive bivalirudin also receive GP IIb/IIIa inhibitors." Dr. Jovin is Medical Director of the Cardiac Catheterization Laboratories at McGuire Veterans Affairs Medical Center and Associate Professor of Medicine at Virginia Commonwealth University in Richmond, Virginia.