Bivalirudin versus heparin during intervention in acute coronary syndrome: A systematic review of randomized trials

• Type of Material: Article
• Authors: Sukhdeep Bhogal, East Tennessee State University; Debabrata Mukherjee, Texas Tech University; Jayant Bagai, Vanderbilt University Medical Center; Huu T. Truong, University of Arizona College of Medicine – Tucson; Hemang B. Panchal, Columbia University; Ghulam Murtaza, East Tennessee State University; Mustafa Zaman, Bangabandhu Sheikh Mujib Medical University; Rajesh Sachdeva, Emory University; Timir K. Paul, East Tennessee State University
• Language: English
• Date: 2020-01-01
• Publisher: Bentham
• Publication Version: Final Published Version
• Copyright Statement: © 2020 Bentham Science Publishers
• License: Creative Commons Attribution-NonCommercial 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.2174/1871529X19666190626124057
• Title of Journal or Parent Work: Cardiovascular and Hematological Disorders - Drug Targets
• Volume: 20
• Issue: 1
• Start Page: 3
• End Page: 15
• Grant/Funding Information: None.
• Keywords: Hirudins; stentthrombosis.; bleeding events; Female; Recombinant Proteins; Anticoagulants; Antithrombins; Treatment Outcome; Humans; Percutaneous Coronary Intervention; Acute Coronary Syndrome; Heparin; Male; Peptide Fragments; glycoprotein IIb/IIIa inhibitors; Randomized Controlled Trials as Topic; percutaneous coronary intervention; bivalirudin
• Research Categories: Chemistry, Pharmaceutical; Health Sciences, Medicine and Surgery

Abstract

Introduction: Bivalirudin and heparin are the two most commonly used anticoagulants used during Percutaneous Coronary Intervention (PCI). The results of Randomized Controlled Trials (RCTs) comparing bivalirudin versus heparin monotherapy in the era of radial access are controversial, questioning the positive impact of bivalirudin on bleeding. The purpose of this systematic review is to summarize the results of RCTs comparing the efficacy and safety of bivalirudin versus heparin with or without Glycoprotein IIb/IIIa Inhibitors (GPI). Methods: This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA statements for reporting systematic reviews. We searched the National Library of Medicine PubMed, Clinicaltrial.gov and the Cochrane Central Register of Controlled Trials to include clinical studies comparing bivalirudin with heparin in patients undergoing PCI. Sixteen studies met inclusion criteria and were reviewed for the summary. Findings: Several RCTs and meta-analyses have demonstrated the superiority of bivalirudin over heparin plus routine GPI use in terms of preventing bleeding complications but at the expense of increased risk of ischemic complications such as stent thrombosis. The hypothesis of post-PCI bivalirudin infusion to mitigate the risk of acute stent thrombosis has been tested in various RCTs with conflicting results. In comparison, heparin offers the advantage of having a reversible agent, of lower cost and reduced incidence of ischemic complications. Conclusion: Bivalirudin demonstrates its superiority over heparin plus GPI with better clinical outcomes in terms of less bleeding complications, thus making it as anticoagulation of choice particularly in patients at high risk of bleeding. Further studies are warranted for head to head comparison of bivalirudin to heparin monotherapy to establish an optimal heparin dosing regimen and post-PCI bivalirudin infusion to affirm its beneficial effect in reducing acute stent thrombosis.