Use and Effectiveness of Bivalirudin Versus Unfractionated Heparin for Percutaneous Coronary Intervention Among Patients With ST-Segment Elevation Myocardial Infarction in the United States

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• 作者：Eric A. Secemsky ; MD ; MSc^a ; ^b ; ^c ; Ajay Kirtane ; MD ; SM^d ; Sripal Bangalore ; MD ; MHA^e ; Ion S. Jovin ; MD^f ; Rachit M. Shah ; MBBS^f ; Enrico G. Ferro ; BS^b ; Neil J. Wimmer ; MD ; MSc^g ; Matthew Roe ; MD ; MHS^h ; Dadi Dai ; PhD^h ; Laura Mauri ; MD ; MSc^b ; ⁱ ; Robert W. Yeh ; MD ; MSc^b ; ^c ; ^{ryeh@bidmc.harvard.edu}
• 关键词：bivalirudin ; bleeding ; mortality ; percutaneous coronary intervention ; ST-segment elevation myocardial infarction
• 刊名：JACC: Cardiovascular Interventions
• 出版年：2016
• 出版时间：12 December 2016
• 年：2016
• 卷：9
• 期：23
• 页码：2376-2386
• 全文大小：1194 K
• 卷排序：9

文摘

The purpose of this study was to describe temporal trends and determine the comparative effectiveness of bivalirudin versus unfractionated heparin (UFH) during percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).BackgroundSeveral clinical trials have compared the safety and effectiveness of bivalirudin versus UFH during PCI for STEMI, but results have been conflicting.MethodsTrends in anticoagulant use were examined among 513,775 PCIs for STEMI from July 2009 through December 2014 within the National Cardiovascular Data Registry CathPCI Registry. We conducted an instrumental variable analysis comparing bivalirudin with UFH, using operator preference for bivalirudin as the instrument. We used a test of mediation to determine the extent to which differences in outcomes between anticoagulants were due to differences in use of glycoprotein IIb/IIIa inhibitors (GPI). Primary outcomes were in-hospital bleeding and mortality.ResultsBivalirudin use increased from 2009 through 2013, followed by a new decline. GPIs were used in 74.7% of UFH PCIs versus 26.5% of bivalirudin PCIs. In unadjusted analyses, bivalirudin was associated with decreased bleeding (risk difference [RD]: -4.2%; p < 0.001) and mortality (RD: -0.84%; p < 0.001). After instrumental variable analyses, bivalirudin remained associated with less bleeding (RD: -3.75%; p < 0.001), but not mortality (RD: -0.10%; p = 0.280). The higher rate of GPI use with UFH was responsible for more than one-half of bivalrudin’s bleeding reduction (GPI-adjusted RD: -1.57%; p < 0.001). Bleeding reductions were negligible for transradial PCI (RD: -0.11%; p = 0.842).ConclusionsThe use of bivalirudin during STEMI has decreased. Bivalirudin was associated with reduced bleeding and no mortality difference. The bleeding reduction with bivalirudin was largely explained by the greater use of GPIs with UFH.