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Oli PR, Shrestha DB, Shtembari J, Gyawali P, Regmi L, Bhandari A, Dhungel S, Mattumpuram J, Pant K, Mungee S. Bivalirudin versus heparin in STEMI after BRIGHT-4 trial: an updated meta-analysis. Coron Artery Dis 2023; 34:562-579. [PMID: 37865864 DOI: 10.1097/mca.0000000000001289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
BACKGROUND The use of bivalirudin-based anticoagulation over heparin-based anticoagulation for coronary percutaneous intervention has been debated for a long time. Multiple trials have shown promising benefits of bivalirudin over heparin therapy with the most recent addition being the BRIGHT-4 trial. We performed a meta-analysis to assess evidence from these trials, focusing on the coronary intervention of the STEMI population. METHODS This meta-analysis was performed based on PRISMA guidelines after registering in PROSPERO (CRD42023394701). Databases were searched for relevant articles published before January 2023. Pertinent data from the included studies were extracted and analyzed using RevMan v5.4. RESULTS Out of 2375 studies evaluated, 13 randomized control trials with 24 360 acute ST-elevation myocardial infarction patients were included for analysis. The bivalirudin-based anticoagulation reduced the net clinical events (OR 0.75, CI 0.61-0.92), major adverse cardiac or cerebral events (OR 0.85, CI 0.74-0.98), any bleeding (OR 0.61, CI 0.45-0.83), major bleeding (OR 0.54, CI 0.39-0.75), all-cause mortality (OR 0.79, CI 0.67-0.92) and cardiac mortality (OR 0.78, CI 0.65-0.93) significantly without increasing the risk of any stent thrombosis (OR 0.92, 95% CI 0.52-1.61), definite stent thrombosis (OR 1.17, 95% CI 0.62-2.22) and acute stent thrombosis (OR 2.06, 95% CI 0.69-6.09) significantly at 30 days. CONCLUSION Based on this meta-analysis, bivalirudin plus a post-PCI high-dose infusion-based anticoagulation during STEMI PCI has significant benefits over heparin therapy for cardiovascular outcomes without a significant increase in the risk of thrombotic outcomes.
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Affiliation(s)
- Prakash Raj Oli
- Department of Internal Medicine, Karnali Province Hospital, Birendranagar, Nepal
| | | | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, Illinois, USA
| | - Pratik Gyawali
- Department of Internal Medicine, Om Saibaba Memorial Hospital, Kathmandu
| | - Laxmi Regmi
- Department of Internal Medicine, Karnali Province Hospital, Birendranagar
| | - Amit Bhandari
- Department of Internal Medicine, Sait Johns Hospital, HSHS Medical Group, Springfield
| | - Swati Dhungel
- Department of Internal Medicine, Division of Cardiovascular Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | - Jishanth Mattumpuram
- Division of Cardiology, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Kailash Pant
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Illinois College of Medicine, OSF Healthcare, Peoria, Illinois, USA
| | - Sudhir Mungee
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Illinois College of Medicine, OSF Healthcare, Peoria, Illinois, USA
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Faour A, Collins N, Williams T, Khan A, Juergens CP, Lo S, Walters DL, Chew DP, French JK. Reperfusion After Fibrinolytic Therapy (RAFT): An open-label, multi-centre, randomised controlled trial of bivalirudin versus heparin in rescue percutaneous coronary intervention. PLoS One 2021; 16:e0259148. [PMID: 34699549 PMCID: PMC8547635 DOI: 10.1371/journal.pone.0259148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The safety and efficacy profile of bivalirudin has not been examined in a randomised controlled trial of patients undergoing rescue PCI. OBJECTIVES We conducted an open-label, multi-centre, randomised controlled trial to compare bivalirudin with heparin ± glycoprotein IIb/IIIa inhibitors (GPIs) in patients undergoing rescue PCI. METHODS Between 2010-2015, we randomly assigned 83 patients undergoing rescue PCI to bivalirudin (n = 42) or heparin ± GPIs (n = 41). The primary safety endpoint was any ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) bleeding at 90 days. The primary efficacy endpoint was infarct size measured by peak troponin levels as a multiple of the local upper reference limit (Tn/URL). Secondary endpoints included periprocedural change in haemoglobin adjusted for red cells transfused, TIMI (Thrombolysis in Myocardial Infarction) bleeding, ST-segment recovery and infarct size determined by the Selvester QRS score. RESULTS The trial was terminated due to slow recruitment and futility after an interim analysis of 83 patients. The primary safety endpoint occurred in 6 (14%) patients in the bivalirudin group (4.8% GPIs) and 3 (7.3%) in the heparin ± GPIs group (54% GPIs) (risk ratio, 1.95, 95% confidence interval [CI], 0.52-7.3, P = 0.48). Infarct size was similar between the two groups (mean Tn/URL, 730 [±675] for bivalirudin, versus 984 [±1585] for heparin ± GPIs, difference, 254, 95% CI, -283-794, P = 0.86). There was a smaller decrease in the periprocedural haemoglobin level with bivalirudin than heparin ± GPIs (-7.5% [±15] versus -14% [±17], difference, -6.5%, 95% CI, -0.83-14, P = 0.0067). The rate of complete (≥70%) ST-segment recovery post-PCI was higher in patients randomised to heparin ± GPIs compared with bivalirudin. CONCLUSIONS Whether bivalirudin compared with heparin ± GPI reduces bleeding in rescue PCI could not be determined. Slow recruitment and futility in the context of lower-than-expected bleeding event rates led to the termination of this trial (ANZCTR.org.au, ACTRN12610000152022).
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Affiliation(s)
- Amir Faour
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Nicholas Collins
- Department of Cardiology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Trent Williams
- Department of Cardiology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Arshad Khan
- Department of Cardiology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Craig P. Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Darren L. Walters
- University of Queensland, Brisbane, Queensland, Australia
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Derek P. Chew
- Department of Cardiology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - John K. French
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute and Western Sydney University, Sydney, New South Wales, Australia
- * E-mail:
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Shavadia JS, Granger CB, Alemayehu W, Westerhout CM, Povsic TJ, Van Diepen S, Defilippi C, Armstrong PW. Novel Biomarkers, ST-Elevation Resolution, and Clinical Outcomes Following Primary Percutaneous Coronary Intervention. J Am Heart Assoc 2020; 9:e016033. [PMID: 32552321 PMCID: PMC7670520 DOI: 10.1161/jaha.120.016033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Despite restoration of epicardial flow following primary percutaneous coronary intervention (PPCI), microvascular reperfusion as reflected by ST-elevation resolution (ST-ER) resolution remains variable and its pathophysiology remains unclear. Methods and Results Using principal component analyses, we explored associations between 91 serum biomarkers drawn before PPCI clustered into 14 pathobiologic processes (including NT-proBNP [N-terminal pro-B-type natriuretic peptide] as an independent cluster), and (1) ST-ER resolution ≥50% versus <50%; and (2) 90-day composite of death, shock, and heart failure. Network analyses were performed to understand interbiomarker relationships between the ST-ER groups. Among the 1160 patients studied, 861 (74%) had ST-ER ≥50% at a median 40 (interquartile range, 23-70) minutes following PPCI, yet both groups had comparable post-PPCI TIMI (Thrombolysis in Myocardial Infarction) grade 3 flow (86.6% versus 82.9%; P=0.25). ST-ER ≥50% was associated with significantly lower pre-PPCI concentrations of platelet activation cluster (particularly P-selectin, von Willebrand factor, and platelet-derived growth factor A) and NT-proBNP, including after risk adjustment. Across both ST-ER groups, strong interbiomarker relationships were noted between pathways indicative of myocardial stretch, platelet activation, and inflammation, whereas with ST-ER <50% correlations between iron homeostasis and inflammation were observed. Of all 14 biomarker clusters, only NT-proBNP was significantly associated with the 90-day clinical composite. Conclusions Suboptimal ST-ER is common despite achieving post-PPCI TIMI grade 3 flow. The cluster of platelet activation proteins and NT-proBNP were strongly correlated with suboptimal ST-ER and NT-proBNP was independently associated with 90-day outcomes. This analysis provides insights into the pathophysiology of microvascular reperfusion in ST-segment-elevation myocardial infarction and suggests novel pre-PPCI risk targets potentially amenable to enhancing tissue-level reperfusion following PPCI.
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Affiliation(s)
- Jay S Shavadia
- Duke Clinical Research Institute Durham NC.,Canadian VIGOUR Centre University of Alberta Edmonton Alberta Canada
| | | | | | | | | | - Sean Van Diepen
- Canadian VIGOUR Centre University of Alberta Edmonton Alberta Canada
| | | | - Paul W Armstrong
- Canadian VIGOUR Centre University of Alberta Edmonton Alberta Canada
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ECG analysis in patients with acute coronary syndrome undergoing invasive management: rationale and design of the electrocardiography sub-study of the MATRIX trial. J Electrocardiol 2019; 57:44-54. [PMID: 31491602 DOI: 10.1016/j.jelectrocard.2019.08.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 08/18/2019] [Accepted: 08/27/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The twelve‑lead electrocardiogram (ECG) has become an essential tool for the diagnosis, risk stratification, and management of patients with acute coronary syndromes (ACS). However, several areas of residual controversies or gaps in evidence exist. Among them, P-wave abnormalities identifying atrial ischemia/infarction are largely neglected in clinical practice, and their diagnostic and prognostic implications remain elusive; the value of ECG to identify the culprit lesion has been investigated, but validated criteria indicating the presence of coronary occlusion in patients without ST-elevation are lacking; finally, which criteria among the multiple proposed, better define pathological Q-waves or success of revascularisation deserve further investigations. METHODS The Minimizing Adverse hemorrhagic events via TRansradial access site and systemic Implementation of AngioX (MATRIX) trial was designed to test the impact of bleeding avoidance strategies on ischemic and bleeding outcomes across the whole spectrum of patients with ACS receiving invasive management. The ECG-MATRIX is a pre-specified sub-study of the MATRIX programme which aims at analyzing the clinical value of ECG metrics in 4516 ACS patients (with and without ST-segment elevation in 2212 and 2304 cases, respectively) with matched pre and post-treatment ECGs. CONCLUSIONS This study represents a unique opportunity to further investigate the role of ECGs in the diagnosis and risk stratification of ACS patients with or without ST-segment deviation, as well as to assess whether the radial approach and bivalirudin may affect post-treatment ECG metrics and patterns in a large contemporary ACS population.
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