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Nadtochiy SM, Stefanos T, Wissler R, Gu Y, Feng C, Lebedko N, Eaton MP. Effect of bivalirudin on coagulation in neonatal (cord) and adult human blood in vitro. Paediatr Anaesth 2024; 34:415-421. [PMID: 38055634 DOI: 10.1111/pan.14814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Bivalirudin is recommended as an alternative to heparin in cardiac surgery with cardiopulmonary bypass. Although it has been used in infants and children for this indication, there is a paucity of data on the pharmacologic effects of bivalirudin in neonates. Given the immaturity of the hemostatic system in neonates, we hypothesized that coagulation responses to bivalirudin in this population would be different than in adults. METHODS Blood samples were drawn from placenta-cord units and from healthy adult donors. The study was carried out in two steps. First, bivalirudin was added to cord and adult blood samples at concentrations of 0, 5, 10, 15, and 20 μg/mL. Activated clotting time and thromboelastographic variables were recorded. Next, we used a Chandler loop system to assess the efficacy of bivalirudin in a simple model of cardiopulmonary bypass. The loops were primed with cord or adult blood and were run until thrombus was detected. Plasma bivalirudin concentrations were measured at 1, 15, 30, 45, 60, and 75 min after initiating rotation of the loops using liquid chromatography/mass spectrometry. RESULTS Bivalirudin elicited a dose-dependent prolongation inhibition of coagulation in both cord and adult blood samples with greater potency in cord blood in comparison to adult blood (activated clotting time: 627 ± 50 vs. 452 ± 22 s at 15 μg/mL bivalirudin, p < .0001). This relative potency was also demonstrated in the Chandler loop system, but interestingly, cord blood appeared to inactivate bivalirudin more rapidly than adult blood with earlier clotting in loops containing cord blood. CONCLUSIONS This study demonstrates that bivalirudin has greater potency in cord blood in vitro than in adult blood. Plasma degradation appears to proceed more rapidly in cord blood than in adults. Both of these findings should be considered when planning dosing regimens in neonatal patients.
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Affiliation(s)
- Sergiy M Nadtochiy
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Tatsiana Stefanos
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Richard Wissler
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Yang Gu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Changyong Feng
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Natalie Lebedko
- School of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Michael P Eaton
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Priest JR, Hebert D, Jutras C. Anticoagulation during extracorporeal membrane oxygenation: A narrative review. Perfusion 2024:2676591241250288. [PMID: 38671589 DOI: 10.1177/02676591241250288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Extracorporeal Membrane Oxygenation (ECMO) is a technology that offers organ support for critically ill patients with respiratory and/or cardiac failure. Despite improvements in recent years in technology and the biocompatibility of circuits, patients on ECMO remain at high risk of hematologic complications, such as bleeding or thrombosis. Anticoagulation is required in most cases to limit the risk of clotting, but questions persist regarding the optimal anticoagulation strategy. More precisely, there is still debate around the best anticoagulation agent and monitoring tools as well as on the transfusion thresholds and appropriate corrective measures when faced with complications. This narrative review provides an overview of hemostasis on ECMO and the impact of circuit size and coating. The benefits and downsides of unfractionated heparin (UHF) and Direct Thrombin Inhibitors (DTIs) as anticoagulation agents are reviewed. Finally, commonly available coagulation tests (activated clotting time, activated partial thrombin time, anti-Xa, and viscoelastic tests) and their limitations are addressed. In conclusion, future research is needed to determine the best anticoagulation strategy for patients on ECMO.
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Affiliation(s)
- John R Priest
- ECMO Program, Department of Respiratory Care, Lifespan Hospital System, Providence, RI, USA
| | - David Hebert
- ECMO Program, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA
- Innovative ECMO Consults, Bluffton, SC, USA
| | - Camille Jutras
- Department of Anesthesiology, Boston Children's Hospital, Critical Care and Pain Medicine, Boston, MA, USA
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Kido K, Kabulski GM, Szymanski TW, Shiga T, Shimizu M, Hashiguchi M. Meta-Analysis Comparing Bivalirudin Versus. Unfractionated Heparin in Adult Patients With Extracorporeal Membrane Oxygenation. J Pharm Pract 2024; 37:429-434. [PMID: 36449392 DOI: 10.1177/08971900221143406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Introduction: Unfractionated heparin (UFH) has traditionally been the agent of choice in patients on extracorporeal membrane oxygenation (ECMO). However, direct thrombin inhibitors (DTI) have recently garnered more attention in ECMO because of their advantages over UFH. Given the heterogeneous results of multiple recent published studies, we performed a meta-analysis to describe pooled outcomes between bivalirudin and UFH anticoagulation in patients on ECMO. Methods: Relevant studies were identified from MEDLINE and Google Scholar database searches through April 23, 2022. The primary efficacy outcome was thromboembolism (TE), and secondary efficacy outcomes included all-cause mortality and circuit thrombosis. The primary safety outcome was major bleeding. Results: A total of 6 studies were included in the meta-analysis. Bivalirudin use was associated with significantly lower risk of TE (OR 0.61; 95% CI 0.38-.99; P = .05; I2 = 0%) and circuit thrombosis (OR 0.51; 95% CI .32-.80; P = .004; I2 = 0%) compared with UFH. There was no significant difference in all-cause mortality risk (OR 0.75; 95% CI .52-1.09; P = .13; I2 = 30%) between the bivalirudin and UFH groups. No significant difference in the risk of major bleeding between 2 groups was found (OR 0.67; 95% CI 0.25-1.81; P = .43; I2 = 80%). Conclusion: These data support that bivalirudin is a reasonable alternative to UFH in patients on ECMO. Randomized controlled trials are needed to confirm bivalirudin's efficacy and safety results compared with UFH.
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Affiliation(s)
- Kazuhiko Kido
- Department of Clinical Pharmacy, West Virginia University School of Pharmacy, Morgantown, WV, USA
| | - Galen M Kabulski
- Department of Pharmacy, Ruby Memorial Hospital, Morgantown, WV, USA
| | | | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and Therapeutics, The Tokyo Jikei University School of Medicine, Tokyo, Japan
| | - Mikiko Shimizu
- Department of Pharmaceutics and Pharmacometrics, School of Pharmacy, Shujitsu University, Okayama, Japan
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Kartika T, Mathews R, Migneco G, Bundy T, Kaempf AJ, Pfeffer M, DeLoughery TG, Moore K, Beardshear R, Oetken HJ, Case J, Hinds MT, McCarty OJT, Shatzel JJ, Zonies D, Zakhary B. Comparison of bleeding and thrombotic outcomes in veno-venous extracorporeal membrane oxygenation: Heparin versus bivalirudin. Eur J Haematol 2024; 112:566-576. [PMID: 38088062 PMCID: PMC11034845 DOI: 10.1111/ejh.14146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 01/17/2024]
Abstract
OBJECTIVES We aimed to evaluate thrombotic and hemorrhagic complications with heparin versus bivalirudin use in veno-venous extracorporeal membrane oxygenation (V-V ECMO). METHODS We performed a retrospective cohort study of adult patients placed on V-V ECMO with intravenous anticoagulation with either heparin or bivalirudin. Time to thrombotic event and major bleed were analyzed in addition to related outcomes. RESULTS We identified 95 patients placed on V-V ECMO: 61 receiving heparin, 34 bivalirudin. The bivalirudin group had a higher rate of severe COVID-19, higher BMI, and longer ECMO duration. Despite this, bivalirudin was associated with reduced risk of thrombotic event (HR 0.14, 95% CI 0.06-0.32, p < .001) and increased average lifespan of the circuit membrane lung (16 vs. 10 days, p = 0.004). While there was no difference in major bleeding, the bivalirudin group required fewer transfusions of packed red blood cells and platelets per 100 ECMO days (means of 13 vs. 39, p = 0.004; 5 vs. 19, p = .014, respectively). Lastly, the bivalirudin group had improved survival to ECMO decannulation in univariate analysis (median OS 53 vs. 26 days, p = .015). CONCLUSIONS In this real-world analysis of bivalirudin versus heparin, bivalirudin is a viable option for V-V ECMO and associated with lower risk of thrombotic complications and fewer transfusion requirements.
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Affiliation(s)
- Thomas Kartika
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | - Rick Mathews
- Department of Biomedical Engineering, Oregon Health & Science University, OR USA
| | - Gina Migneco
- Department of Pharmacy, Oregon Health & Science University, Portland, OR USA
| | - Taylor Bundy
- Department of Internal Medicine, Oregon Health & Science University, Portland, OR USA
| | - Andy J Kaempf
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | - Michael Pfeffer
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | - Thomas G DeLoughery
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | - Kerry Moore
- Department of Pharmacy, Oregon Health & Science University, Portland, OR USA
| | - Rachel Beardshear
- Department of Pharmacy, Oregon Health & Science University, Portland, OR USA
| | - Heath J Oetken
- Department of Pharmacy, Oregon Health & Science University, Portland, OR USA
| | - Jonathan Case
- Department of Pharmacy, Oregon Health & Science University, Portland, OR USA
| | - Monica T Hinds
- Department of Biomedical Engineering, Oregon Health & Science University, OR USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, OR USA
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
- Department of Biomedical Engineering, Oregon Health & Science University, OR USA
| | - David Zonies
- Department of Surgery, Oregon Health & Science University, Portland, OR USA
| | - Bishoy Zakhary
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR USA
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Haffler ZJ, Hughes TG, Yeager LS. Intraoperative Bivalirudin Use in Patient Undergoing Femoral Endarterectomy with Heparin-Induced Thrombocytopenia: Case Report and Review of the Literature. Vasc Endovascular Surg 2024; 58:452-456. [PMID: 38016142 DOI: 10.1177/15385744231216034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
PURPOSE To describe the intraoperative use of bivalirudin during lower extremity revascularization in the setting of heparin-induced thrombocytopenia (HIT). CASE SUMMARY A 65 year-old man presented with left common iliac, external iliac, and femoral artery occlusion necessitating revascularization with left femoral endarterectomy and common and external iliac stent angioplasty. Three months before the femoral endarterectomy, the patient was hospitalized for a coronary artery bypass procedure. During this admission, the patient tested positive for the presence of heparin-PF4 antibody complexes. With the patient's recent history of HIT, bivalirudin was selected as the optimal agent for intraoperative anticoagulation. Bivalirudin was administered as a 50 mg bolus, followed by a continuous infusion initiated at 1.75 mg/kg/hr. Repeated bivalirudin boluses were necessary to maintain an activated clotting time (ACT) necessary for the revascularization procedures and recurrent subacute thrombi despite appropriate ACT values. DISCUSSION Bivalirudin has been utilized for cardiopulmonary bypass and carotid endarterectomy (CEA), but data for dosing in lower extremity revascularization are lacking. As the risk for thrombosis with HIT continues for months after diagnosis, it is important to elucidate optimal dosing of non-heparin anticoagulant options, such as the direct thrombin inhibitor, bivalirudin. The absence of validated dosing strategies for bivalirudin can result in prolonged operative times, increased risk of bleeding, and inadequate anticoagulation. CONCLUSION Bivalirudin is an appropriate agent for intraoperative anticoagulation in lower extremity revascularization. However, further investigation into the optimal intraoperative bivalirudin dosing regimen is necessary.
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Affiliation(s)
- Zachary J Haffler
- Department of Pharmacy, UK HealthCare, Lexington, KY, USA
- Department of Pharmacy, Pharmacy Practice and Science Department, UK College of Pharmacy, UK HealthCare, Lexington, KY, USA
| | - Travis G Hughes
- Division of Vascular and Endovascular Surgery, UK HealthCare, Lexington, KY, USA
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Plourde C, Beauchamp FO, Brocks R, Thibault C. Successful decompressive laparotomy in a neonate with abdominal compartment syndrome on extracorporeal membrane oxygenation following congenital diaphragmatic hernia repair. Perfusion 2024; 39:607-611. [PMID: 36537252 DOI: 10.1177/02676591221147436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
Abdominal compartment syndrome (ACS) is a rare complication of extracorporeal membrane oxygenation (ECMO) and is associated with high morbidity and mortality. Despite being the treatment of choice for ACS, decompressive laparotomy (DL) has been a matter of debate in children supported with ECMO due to high bleeding risk and presumed futility. We report the first neonatal DL for ACS while on ECMO following congenital diaphragmatic hernia (CDH) repair. Given its excellent outcomes, our case challenges current literature and supports prompt bedside laparotomy to treat ACS on neonatal ECMO.
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Affiliation(s)
- Camille Plourde
- Division of Pediatric General Surgery, Department of Surgery, CHU Sainte-Justine, Montreal, QC, Canada
| | - Francis-Olivier Beauchamp
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Rebecca Brocks
- Division of Pediatric General Surgery, Department of Surgery, CHU Sainte-Justine, Montreal, QC, Canada
| | - Céline Thibault
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
- CHUSJ Research Center, Université de Montréal, Montreal, QC, Canada
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Li Q, Li H, Liu Z, Duan L. Bivalirudin versus Heparin on Net Adverse Clinical Events, Major Adverse Cardiac and Cerebral Events, and Bleeding in Elderly Chinese Patients Treated with Percutaneous Coronary Intervention. TOHOKU J EXP MED 2024; 262:115-124. [PMID: 37821386 DOI: 10.1620/tjem.2023.j085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Bivalirudin as an anticoagulant reduces bleeding after percutaneous coronary intervention (PCI), while its impact in elderly Chinese patients treated with PCI needs more evidence. This study aimed to compare the clinical outcomes between bivalirudin and heparin in elderly Chinese patients treated with PCI. This cohort study retrieved data of 1,286 elderly patients treated with PCI who used bivalirudin (bivalirudin group, N = 493) or heparin (heparin group, N = 793) as anticoagulants. Net adverse clinical events (NACEs) (primary endpoint), major adverse cardiac and cerebral events (MACCEs), bleeding, and major bleeding within 30 days after PCI treatment were recorded for analysis. Our study illustrated that NACEs (12.4% vs. 17.4%, P = 0.015), bleeding (6.7% vs. 12.1%, P = 0.002), and major bleeding (2.2% vs. 6.6%, P < 0.001) were fewer in bivalirudin group compared to heparin group. No difference was found in MACCEs (7.5% vs. 9.6%,P = 0.200), and incidences of all-cause mortality (P = 0.257), cardiac mortality (P = 0.504), recurrent myocardial infarction (P = 0.423), ischemia-driven revascularization (P = 0.509), and stroke (P = 0.467), between bivalirudin group and heparin group. According to univariate logistic regression analyses, bivalirudin (vs. heparin) correlated with fewer NACEs (P = 0.016), bleeding (P = 0.002), and major bleeding (P = 0.001) in elderly patients treated with PCI, but not MACCEs (P = 0.202). After adjustment, bivalirudin (vs. heparin) was an independent factor for fewer NACEs [odds ratio (OR): 0.619, P = 0.009], bleeding (OR: 0.499, P = 0.003), and major bleeding (OR: 0.342, P = 0.003) in these patients. In summary, bivalirudin achieves fewer NACEs, bleeding, and major bleeding, but not MACCEs, versus heparin in elderly patients treated with PCI, which is verified in the multivariate model.
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Affiliation(s)
- Qin Li
- Department of Pharmacy, The Affiliated Hospital, Southwest Medical University
| | - Huayun Li
- Department of Pharmacy, The Affiliated Hospital, Southwest Medical University
| | - Zhongfei Liu
- Department of Pharmacy, The Affiliated Hospital, Southwest Medical University
| | - Lingxiao Duan
- Department of Critical Care Medicine, The Affiliated Hospital, Southwest Medical University
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Li Y, Li Y, Qiu M, Xue Y, Xu K, Han Y. Ticagrelor vs clopidogrel when coadministered with bivalirudin in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Res Pract Thromb Haemost 2024; 8:102375. [PMID: 38623472 PMCID: PMC11017352 DOI: 10.1016/j.rpth.2024.102375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 12/11/2023] [Accepted: 01/05/2024] [Indexed: 04/17/2024] Open
Abstract
Background The optimal perioperative antithrombotic strategy for patients with acute coronary syndrome (ACS) during percutaneous coronary intervention (PCI) remains controversial. Objectives To determine the safety and effectiveness of bivalirudin plus ticagrelor vs bivalirudin plus clopidogrel in patients with ACS undergoing PCI in the real world. Methods Between March 2016 and March 2019, 7234 patients with ACS who had undergone PCI, received bivalirudin periprocedurally, and were prescribed ticagrelor or clopidogrel were enrolled in a single-center, all-comer, modern, retrospective cohort study. Incidence rates of 12-month ischemia (cardiac death, myocardial infarction, or stroke), all-cause death, Bleeding Academic Research Consortium (BARC) type 2,3,5 bleeding, and BARC type 3,5 bleeding were compared between different groups. Results In total, 4960 patients received bivalirudin plus clopidogrel and 2274 patients received bivalirudin plus ticagrelor. Compared with bivalirudin plus clopidogrel, bivalirudin plus ticagrelor was associated with lower ischemic events (1.74% vs 2.84%; relative risk, 0.61; 95% CI, 0.41-0.91; P = .02) and stroke (0.05% vs 1.01%, P < .001) within 12 months after PCI without excessive risk of bleeding (BARC type 2,3,5 bleeding: 4.49% vs 3.76%, P = .22; BARC type 3,5 bleeding: 2.84% vs 2.02%, P = .08). The beneficial effects of bivalirudin plus ticagrelor were consistent among subgroups. Conclusion As an initial treatment strategy, bivalirudin plus ticagrelor could reduce the 12-month risk of ischemic events compared with bivalirudin plus clopidogrel significantly without increasing the bleeding risk in ACS patients undergoing PCI.
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Affiliation(s)
- Yang Li
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yi Li
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Miaohan Qiu
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yu Xue
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Kai Xu
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
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Halawi H, Harris JE, Goodarzi A, Yau S, Youssef JG, Botros M, Huang HJ. Use of bivalirudin after initial heparin management among adult patients on long-term venovenous extracorporeal support as a bridge to lung transplant: A case series. Pharmacotherapy 2024; 44:283-289. [PMID: 38304955 DOI: 10.1002/phar.2910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/16/2023] [Accepted: 12/22/2023] [Indexed: 02/03/2024]
Abstract
A growing body of evidence supports the use of bivalirudin as an alternative to unfractionated heparin (UFH) for the prevention of thrombotic events in patients on venovenous (VV) extracorporeal membrane oxygenation (ECMO). However, data in patients bridged to lung transplantation are limited. In this case series, we describe the outcomes of six patients who were transitioned from UFH to bivalirudin during their course of VV ECMO support as a bridge to lung transplantation. All six patients were on VV ECMO support until transplant, with a median duration of 73 days. Bivalirudin demonstrated a shorter time to first therapeutic activated thromboplastin time (aPTT) level. Additionally, time in therapeutic range was longer while patients were receiving bivalirudin compared to UFH (median 92.9% vs. 74.6%). However, major bleeding and thrombotic events occurred while patients were receiving either anticoagulant. Based on our experience, bivalirudin appears to be a viable option for anticoagulation in VV ECMO patients bridged to lung transplantation. Larger studies evaluating the optimal anticoagulation strategy in patients bridged to transplant are needed.
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Affiliation(s)
- Hala Halawi
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Jesse E Harris
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Ahmad Goodarzi
- Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Simon Yau
- Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Jihad G Youssef
- Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Mena Botros
- Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Howard J Huang
- Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas, USA
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10
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Venema R, Dawson K, Faulds J, Walker M. Bolus-only bivalirudin for carotid endarterectomy in a patient with heparin-induced thrombocytopenia. Can J Anaesth 2024; 71:439-440. [PMID: 38216811 DOI: 10.1007/s12630-024-02690-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/15/2023] [Accepted: 11/15/2023] [Indexed: 01/14/2024] Open
Affiliation(s)
- Robertson Venema
- Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, BC, Canada.
| | - Kathryn Dawson
- Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology and Perioperative Care, Vancouver Acute - VGH and UBCH, Vancouver, BC, Canada
| | - Jason Faulds
- Division of Vascular Surgery, Department of Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Matthew Walker
- Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology and Perioperative Care, Vancouver Acute - VGH and UBCH, Vancouver, BC, Canada
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11
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Zhang Y, Zou Z, Xu B, Chen B, Ge H, Ding S, Pu J. Impact of Bivalirudin on Ischemia/Reperfusion Injury in Patients with Reperfused STEMI Assessed by Cardiac Magnetic Resonance. Pharmaceuticals (Basel) 2024; 17:196. [PMID: 38399411 PMCID: PMC10893429 DOI: 10.3390/ph17020196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 02/25/2024] Open
Abstract
Thrombin is an important ischemia/reperfusion injury (IRI) mediator in patients with ST-elevation myocardial infarction (STEMI). This study examines the use of bivalirudin, a direct thrombin inhibitor, in reducing IRI in STEMI patients. STEMI patients (n = 21) were treated with bivalirudin and compared to 21 patients treated with unfractionated heparin (UFH) from the EARLY Assessment of Myocardial Tissue Characteristics by CMR in STEMI (EARLY-MYO-CMR) registry (NCT03768453). Infarct size (IS) and left ventricular ejection fraction (LVEF) were comparable between the two groups at follow up. During the first cardiac magnetic resonance (CMR) scan within the first week after percutaneous coronary intervention (PCI), all patients in both the bivalirudin and UFH groups exhibited myocardial edema. However, the myocardium edema volume was significantly less in the bivalirudin group (p < 0.05). At the one-month follow-up, a smaller proportion of patients in the bivalirudin group than in the UFH group exhibited myocardial edema (4.7% vs. 33.3%, p < 0.05). At the three-month follow-up, myocardial edema had completely resolved in the bivalirudin group, while it persisted in two patients in the UFH group. The incidence and volume of microvascular obstruction (MVO) were significantly lower in the bivalirudin group during the acute phase. Additionally, the incidence of intramyocardial hemorrhage (IMH) was significantly lower in the bivalirudin group during both the acute and follow up (p < 0.05). These findings were corroborated by T2 and T1 mapping results. The study concluded that the use of bivalirudin for anticoagulation is associated with attenuated IRI in STEMI patients who receive primary PCI.
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Affiliation(s)
- Yizhi Zhang
- Department of Cardiology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200002, China; (Y.Z.); (Z.Z.); (B.X.); (H.G.)
| | - Zhiguo Zou
- Department of Cardiology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200002, China; (Y.Z.); (Z.Z.); (B.X.); (H.G.)
| | - Bihe Xu
- Department of Cardiology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200002, China; (Y.Z.); (Z.Z.); (B.X.); (H.G.)
| | - Binghua Chen
- Department of Radiology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200002, China;
| | - Heng Ge
- Department of Cardiology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200002, China; (Y.Z.); (Z.Z.); (B.X.); (H.G.)
| | - Song Ding
- Department of Cardiology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200002, China; (Y.Z.); (Z.Z.); (B.X.); (H.G.)
- Department of Cardiology, Punan Branch of Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
| | - Jun Pu
- Department of Cardiology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200002, China; (Y.Z.); (Z.Z.); (B.X.); (H.G.)
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12
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Lopez ND, Seto SL, Barra ME, Roberts RJ, Rosovsky RP, Solomon EJ, Dalia A. Evaluation of Bivalirudin During Adult Extracorporeal Membrane Oxygenation: A Retrospective Characterization of Dosing, Efficacy and Bleeding. Hosp Pharm 2024; 59:77-85. [PMID: 38223854 PMCID: PMC10786057 DOI: 10.1177/00185787231188924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Objective: Although heparin is the current standard anticoagulant during venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO), factors including heparin-induced thrombocytopenia, heparin resistance and drug shortages necessitate alternative anticoagulants such as direct thrombin inhibitors. The aim was to characterize dosing, safety, and efficacy of bivalirudin during ECMO support. Methods: This retrospective single-center study included 24 adults on ECMO support who received ≥6 hours of bivalirudin. The primary endpoint was dose to first therapeutic activated partial thromboplastin time (aPTT). Secondary endpoints included evaluating dosing between ECMO modes, incidence of bleeding and thrombotic events, and time in therapeutic range (TTR). Results: The dose at time of first therapeutic aPTT was bivalirudin 0.05 [0.05-0.1] mg/kg/hour. Bivalirudin dosing requirements were lower in VAECMO compared to VV-ECMO patients and were not impacted by continuous venovenous hemofiltration. Time to therapeutic aPTT was 5.5 [2-13] hours for VA-ECMO and 4.5 [2-8.6] hours for VV-ECMO patients. During any mode of ECMO TTR was 58.3% [39.6-73.1]. Thrombotic events occurred in 3 (13%) patients and major bleeding occurred in 12 (50%) patients. Conclusions: Our findings demonstrated variable bivalirudin dosing requirements based on mode of ECMO and dosing modifications may not be required during CVVH. Factors including mode of ECMO, indication for bivalirudin and concomitant antiplatelet therapy may impact hematologic events. Application of this data can assist with developing a bivalirudin ECMO protocol which provides less variability in initial dosing and TTR.
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Affiliation(s)
| | | | | | | | - Rachel P. Rosovsky
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Adam Dalia
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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13
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Chlorogiannis DD, Mavridis T, Adamou A, Kyriakoulis I, Stamatiou I, Botou P, Chen HS, Ntaios G. Argatroban as an Add-On to rtPA in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:563. [PMID: 38256696 PMCID: PMC10816854 DOI: 10.3390/jcm13020563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/05/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
Current treatment options for acute ischemic stroke, including intravenous thrombolysis (IVT) and mechanical thrombectomy, have undoubtedly revolutionized stroke care. The need for additional treatment options has brought into the light direct thrombin inhibitors (DTIs) and, specifically, argatroban as a promising candidate. However, there is uncertainty regarding the safety of adding argatroban to IVT, mainly due to the increased hemorrhagic risk. In this study, we performed a systematic review and meta-analysis examining the safety and efficacy of argatroban as an add-on treatment for IVT. The following databases were searched from inception until the 14th of May 2023: Pubmed/MEDLINE, ClinicalTrials.gov, the EU Clinical Trials Register, EMBASE/Scopus, and the Cochrane Library. Only randomized clinical trials (RCTs) enrolling patients with acute ischemic stroke who underwent IVT evaluating the add-on use of any DTIs were selected for the systematic review and further meta-analysis. The PRISMA guidelines were followed at all stages. Four studies with argatroban were included in the final analysis. Analysis of risk ratio and relative risk shows that the add-on therapy with argatroban seems to be effective and favors a good clinical outcome (mRS 0-2) at 90 days, similar to that of alteplase. All studies showed a low pooled incidence of symptomatic intracerebral hemorrhage (5%), parenchymal hematoma (3%), and other major bleeding (1%). Argatroban as an add-on treatment to IVT seems not to be associated with excessive bleeding risk; however, its efficacy remains unproven. According to this synopsis of the currently available evidence, it is premature to use argatroban as an add-on to IVT treatment outside the current clinical trial setting.
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Affiliation(s)
| | - Theodoros Mavridis
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
- Department of Neurology, Tallaght University Hospital, D24 NR0A Dublin, Ireland
| | - Anastasia Adamou
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (A.A.); (I.K.)
| | - Ioannis Kyriakoulis
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (A.A.); (I.K.)
| | - Iliana Stamatiou
- Department of Internal Medicine, University Hospital of Alexandroupolis, 68100 Alexandroupolis, Greece;
| | - Polyxeni Botou
- Department of Anaesthesiology, Hippocration General Hospital of Athens, 11527 Athens, Greece;
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang 110017, China;
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (A.A.); (I.K.)
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14
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Meshulami N, Murthy R, Meyer M, Meyer AD, Kaushik S. Bivalirudin anticoagulation for cardiopulmonary bypass during cardiac surgery. Perfusion 2023:2676591231221708. [PMID: 38084653 DOI: 10.1177/02676591231221708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Heparin is the primary anticoagulant for cardiopulmonary bypass (CPB) support during cardiac surgery. While widely used, ∼2% of cardiac surgery patients develop heparin-induced thrombocytopenia (HIT) and 4-26% develop heparin resistance. Bivalirudin is an alternative anticoagulant mainly used for percutaneous coronary interventions. Given the challenges associated with heparin anticoagulation, we conducted a review to explore the use of bivalirudin for CPB surgery. METHODS PubMed and Embase scoping review included 2 randomized controlled trials, a retrospective comparison study, 3 pilot studies, and 30 case reports. To provide a contemporary series, we searched for articles published from 2010 to 2023. Our review included studies from both adult and pediatric populations. RESULTS While data is limited, bivalirudin seems to supply similar effectiveness and safety as heparin for CPB anticoagulation. Across the three comparative studies, the heparin cohorts had a 0-9% mortality rate and 0-27% rate of major bleeding/reoperation compared to a 0-3% mortality and 0-6% major bleeding/reoperation rate for the bivalirudin cohorts. Bivalirudin was successfully used as an anticoagulant in a wide range of CPB surgeries (e.g., heart transplants, ventricular assisted device placements, and valve repairs). Successful patient outcomes were reported with bivalirudin infusion of ∼2 mg/kg/hour, activated clotting time monitoring (target >400 s or 2.5× baseline), use of cardiotomy suctions, minimization of stagnant blood, and post-bypass modified ultrafiltration. CONCLUSION Bivalirudin is a safe and effective anticoagulant for CPB, especially for patients with HIT or heparin resistance. Further comparative research is called for to optimize bivalirudin utilization for CPB during cardiac surgery.
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Affiliation(s)
- Noy Meshulami
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raghav Murthy
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Pediatric Cardiac Surgery, Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maisy Meyer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrew D Meyer
- Division of Critical Care, Department of Pediatrics, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Shubhi Kaushik
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Pediatric Critical Care, Department of Pediatrics, Kravis Children's Hospital at Mount Sinai, Icahn School of Medicine, New York, NY, USA
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15
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Graboyes SDT, Owen PS, Evans RA, Berei TJ, Hryniewicz KM, Hollis IB. Review of anticoagulation considerations in extracorporeal membrane oxygenation support. Pharmacotherapy 2023; 43:1339-1363. [PMID: 37519116 DOI: 10.1002/phar.2857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/10/2023] [Accepted: 06/16/2023] [Indexed: 08/01/2023]
Abstract
Since its first success in 1975, extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency for pulmonary and cardiopulmonary bypass. Use in adults has increased exponentially since the early 2000s, but despite thousands of international cannulations using both veno-arterial (VA) and veno-venous (VV) ECMO, there are still significant hemocompatibility-related adverse events. Current management of anticoagulation has been based on the Extracorporeal Life Support Organization guidance published in 2014 with recent updates published in 2022. Despite this guidance, there is still limited international consensus on how to manage anticoagulation in ECMO. For this review, we completed a comprehensive search of multiple electronic databases to identify studies pertaining to anticoagulation of adult patients on VV or VA-ECMO. The highest priority was given to sources that were prospective, randomized, controlled studies, but in the absence of such resources, observational studies, retrospective uncontrolled studies, and case series/reports were considered for inclusion. This document serves to provide a comprehensive review of the current understanding of management pertaining to anticoagulation relating to ECMO.
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Affiliation(s)
- Sydney D T Graboyes
- Department of Pharmacy, University of California, Davis Medical Center, Sacramento, California, USA
| | - Phillip S Owen
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Rickey A Evans
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Theodore J Berei
- Department of Pharmacy, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Katarzyna M Hryniewicz
- Heart Failure Section, Minneapolis Heart Institute at Abbot Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Ian B Hollis
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
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16
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Zhang J, Chen Z, Wang D, Li C, Luo F, He Y. Bivalirudin versus heparin in contemporary percutaneous coronary interventions for patients with acute coronary syndrome: a systematic review and meta-analysis. Cardiol J 2023:VM/OJS/J/90956. [PMID: 37964648 DOI: 10.5603/cj.90956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 03/30/2023] [Accepted: 08/27/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Bivalirudin is associated with fewer major bleeding events than heparin in patients undergoing percutaneous coronary intervention (PCI), but confounding effects of concomitant glycoprotein IIb/IIIa inhibitors, routine femoral artery access, and less potent effects of clopidogrel limits meaningful comparisons. The present study is a systematic review and meta-analysis to compare bivalirudin to heparin in contemporary practice. METHODS The Cochrane Library, PubMed, EMBASE, and Ovid MEDLINE databases were searched for relevant studies, including comparisons between bivalirudin and heparin in the current medical era from inception to December 23, 2021. Studies reporting incidences of major adverse cardiac events (MACE) and net adverse clinical events (NACE) in patients undergoing PCI and meeting the inclusion criteria were retained. Data extraction was performed by three independent reviewers. RESULTS The meta-analysis included 8 studies. Compared to heparin, bivalirudin during PCI was associated with a lower NACE risk, lower all-cause death, and similar MACE risk, with a pooled risk ratio of 0.82 (95% confidence interval [CI] 0.69-0.97, p = 0.02), 0.83 (95% CI 0.74-0.94, p = 0.002), and 0.93 (95% CI 0.78-1.10, p = 0.38), respectively. Moreover, the reduction in NACE was mainly attributed to reduced bleeding (22% reduction in the risk of major bleeding, 95% CI 0.63-0.97, p = 0.03). CONCLUSIONS These findings suggest that bivalirudin use during PCI reduced the risk of NACE and all-cause death but did not reduce the risk of MACE compared with heparin use in PCI. More studies specifically designed for anticoagulation strategies and a personalized anticoagulation regimen to comprehensively balance bleeding and ischemia risks are required.
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Affiliation(s)
- Junyan Zhang
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China.
| | - Zhongxiu Chen
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Chen Li
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Fangbo Luo
- Department of Rehabilitation, Community Health Center of Huaxing Wuhou District, Chengdu, Sichuan, China
| | - Yong He
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
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17
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Bai Z, Wang Z, Feng Q, Zhang Y, Zhang M, Hou A, Wu Y, Qin Z, Chai L. Bivalirudin vs heparin in cardiac-cerebral ischemic and bleeding events among Chinese STEMI patients during percutaneous coronary intervention: a retrospective cohort study. Braz J Med Biol Res 2023; 56:e13013. [PMID: 37970924 PMCID: PMC10644965 DOI: 10.1590/1414-431x2023e13013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/10/2023] [Indexed: 11/19/2023] Open
Abstract
Although bivalirudin has been recently made available for purchase in China, large-scale analyses on the safety profile of bivalirudin among Chinese patients is lacking. Thus, this study aimed to compare the safety profile of bivalirudin and heparin as anticoagulants in Chinese ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI). A total of 1063 STEMI patients undergoing PCI and receiving bivalirudin (n=424, bivalirudin group) or heparin (n=639, heparin group) as anticoagulants were retrospectively enrolled. The net adverse clinical events (NACEs) within 30 days after PCI were recorded, including major adverse cardiac and cerebral events (MACCEs) and bleeding events (bleeding academic research consortium (BARC) grades 2-5 (BARC 2-5)). The incidences of NACEs (10.1 vs 15.6%) (P=0.010), BARC 2-5 bleeding events (5.2 vs 10.3%) (P=0.003), and BARC grades 3-5 (BARC 3-5) bleeding events (2.1 vs 5.5%) (P=0.007) were lower in the bivalirudin group compared to the heparin group, whereas general MACCEs incidence (8.9 vs 6.4%) (P=0.131) and each category of MACCEs (all P>0.05) did not differ between two groups. Furthermore, the multivariate logistic analyses showed that bivalirudin (vs heparin) was independently correlated with lower risk of NACEs (OR=0.508, P=0.002), BARC 2-5 bleeding events (OR=0.403, P=0.001), and BARC 3-5 bleeding events (OR=0.452, P=0.042); other independent risk factors for NACEs, MACCEs, or BARC bleeding events included history of diabetes mellitus, emergency operation, multiple lesional vessels, stent length >33.0 mm, and higher CRUSADE score (all P<0.05). Thus, bivalirudin presented a better safety profile than heparin among Chinese STEMI patients undergoing PCI.
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Affiliation(s)
- Zhichao Bai
- Department of Cardiology, HanDan Central Hospital, Handan, China
| | - Zhenzhen Wang
- Department of Cardiology, HanDan Central Hospital, Handan, China
| | - Qiang Feng
- Department of Cardiology, HanDan Central Hospital, Handan, China
| | - Yapei Zhang
- The Fourth Department of Oncology, HanDan Central Hospital, Handan, China
| | - Mengying Zhang
- Department of Cardiology, HanDan Central Hospital, Handan, China
| | - Aijun Hou
- Department of Cardiology, HanDan Central Hospital, Handan, China
| | - Yiping Wu
- Department of Neurology, HanDan Central Hospital, Handan, China
| | - Zhenpeng Qin
- Information Section, HanDan Central Hospital, Handan, China
| | - Lina Chai
- Department of Cardiology, HanDan Central Hospital, Handan, China
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18
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Chai L, Liu J, Zhang Y, Zhang M, Wang Z, Wu Y, Bai Z, Qin Z. Comparison of net adverse clinical events between bivalirudin and heparin as anticoagulants for percutaneous coronary intervention in Chinese patients. Exp Ther Med 2023; 26:530. [PMID: 37869647 PMCID: PMC10587863 DOI: 10.3892/etm.2023.12229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 09/01/2023] [Indexed: 10/24/2023] Open
Abstract
Bivalirudin, as a direct thrombin inhibitor, is considered to be safer compared with other anticoagulants, such as heparin; however, relevant data in China are unclear. The present study aimed to compare the safety of bivalirudin and heparin as anticoagulants in Chinese patients who underwent percutaneous coronary intervention (PCI). In the present study, 2,377 patients with ST-segment elevation myocardial infarction (STEMI), unstable angina, non-STEMI or stable coronary artery disease who underwent primary PCI while receiving bivalirudin or heparin (low molecular weight heparin or unfractionated heparin) were reviewed, and then analyzed as the bivalirudin group (n=944) and heparin group (n=1,433). The net adverse clinical events (NACEs) within 30 days were obtained, which were defined as major adverse cardiac and cerebral events (MACCEs) + Bleeding Academic Research Consortium (BARC) grade 2-5 bleeding events. Compared with the heparin group, the incidence of NACEs was reduced in the bivalirudin group (9.3 vs. 13.4%; P=0.003). However, no discrepancy was found in the incidence of MACCEs between the groups (5.9 vs. 7.6%; P=0.116). Moreover, the incidences of BARC 2-5 (4.8 vs. 8.7%; P<0.001) and BARC 3-5 bleeding events (1.9 vs. 4.4%; P=0.001) were decreased in the bivalirudin group compared with the heparin group. Following adjustment using multivariate logistic regression analysis, bivalirudin treatment (vs. heparin treatment) was independently associated with lower risks of NACEs [odds ratio (OR), 0.587; P<0.001], MACCEs (OR, 0.689; P=0.041) and BARC 2-5 (OR, 0.459; P<0.001) and 3-5 bleeding events (OR, 0.386; P=0.002). Overall, the present study demonstrated that bivalirudin decreased the risks of NACEs and bleeding events compared with heparin in Chinese patients who undergo PCI. However, further validation is required.
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Affiliation(s)
- Lina Chai
- Department of Cardiology, Handan Central Hospital, Handan, Hebei 056002, P.R. China
| | - Jinjun Liu
- Department of Cardiology, Handan Central Hospital, Handan, Hebei 056002, P.R. China
| | - Yapei Zhang
- The Fourth Department of Oncology, Handan Central Hospital, Handan, Hebei 056002, P.R. China
| | - Mengying Zhang
- Department of Cardiology, Handan Central Hospital, Handan, Hebei 056002, P.R. China
| | - Zhenzhen Wang
- Department of Cardiology, Handan Central Hospital, Handan, Hebei 056002, P.R. China
| | - Yiping Wu
- Department of Neurology, Handan Central Hospital, Handan, Hebei 056002, P.R. China
| | - Zhichao Bai
- Department of Cardiology, Handan Central Hospital, Handan, Hebei 056002, P.R. China
| | - Zhenpeng Qin
- Veteran Cadre Management Section, Handan Central Hospital, Handan, Hebei 056002, P.R. China
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19
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Mitchell M, Sullinger D, Dyer D, Hickey G, Kaczorowski D, Minor J, Murray H, Ramanan R, Rhinehart Z, Schmidhofer M, Rivosecchi RM. Evaluation of Newly Integrated Bivalirudin Titration Protocol in Patients With Mechanical Circulatory Support. Ann Pharmacother 2023:10600280231206130. [PMID: 37887435 DOI: 10.1177/10600280231206130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Patients with cardiogenic shock or end-stage heart failure can be maintained on mechanical circulatory support (MCS) devices. Once a patient undergoes placement of a device, obtaining and maintaining therapeutic anticoagulation is vital. Guidelines recommend the use of institutional protocols to assist in dosing and titration of anticoagulants. OBJECTIVE The purpose of this study was to characterize the use of bivalirudin before and after the implementation of a standardized titration protocol in patients with MCS. METHODS A retrospective review of patients who received bivalirudin for MCS (VA ECMO [veno-arterial extracorporeal membrane oxygenation], Impella, or LVAD [left ventricular assist device]) before and after the implementation of the titration protocol into the electronic health record (EHR) was conducted. The primary outcome was to compare the proportion of therapeutic activated partial thromboplastin time (aPTT). Secondary outcomes included number of subtherapeutic and supratherapeutic aPTTs, incidence of bleeding and clotting events, bivalirudin titrations per day, and percentage of patients with therapeutic aPTT level. RESULTS A total of 100 patients were included (precohort = 67; postcohort = 33). The proportion of therapeutic aPTTs was significantly higher in the postcohort than that in the precohort (62% vs 48%; P < 0.001). The postcohort had 0% of patients failing to achieve therapeutic aPTT levels. The number of titrations per day was significantly lower in the postcohort, with 1.20 titrations per day versus 1.93 in the precohort (P < 0.001). CONCLUSIONS Implementation of the bivalirudin titration nomograms within the EHR significantly increased the number of therapeutic aPTTs, reduced the number of patients who never achieved a therapeutic aPTT, and reduced the required number of titrations per day.
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Affiliation(s)
- Madeline Mitchell
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Danine Sullinger
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Duke Dyer
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gavin Hickey
- Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joni Minor
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Holt Murray
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zachary Rhinehart
- Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark Schmidhofer
- Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ryan M Rivosecchi
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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20
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Navaei A, Kostousov V, Teruya J. Is it time to switch to bivalirudin for ECMO anticoagulation? Front Med (Lausanne) 2023; 10:1237601. [PMID: 37671395 PMCID: PMC10476497 DOI: 10.3389/fmed.2023.1237601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/31/2023] [Indexed: 09/07/2023] Open
Abstract
For decades, unfractionated heparin (hereafter, heparin) has been the primary anticoagulant used for extracorporeal membrane oxygenation (ECMO) support. More recently, however, bivalirudin, a direct thrombin inhibitor, has emerged as an alternative. This systematic review based on PRISMA guidelines, aims to summarize 16 comparative studies and 8 meta-analysis and review articles published from January, 2011 till May, 2023 which directly compares ECMO courses using heparin versus bivalirudin as the anticoagulant. While this comparison is complicated by the lack of a standardized definition of major bleeding or thrombosis, our overall findings suggest there is no statistical difference between heparin and bivalirudin in incidence of bleeding and thrombosis. That said, some studies found a statistical significance favoring bivalirudin in reducing major bleeding, thrombosis, and the need for transfusions. We also offer essential guidance for appropriately selecting an anticoagulant and monitoring its effect in ECMO settings.
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Affiliation(s)
- Amir Navaei
- Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Vadim Kostousov
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Jun Teruya
- Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
- Department of Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
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21
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Teruya J, Connors JM, Zieger B. Editorial: Hemostasis in ECMO and VAD, volume II. Front Med (Lausanne) 2023; 10:1251079. [PMID: 37547604 PMCID: PMC10403285 DOI: 10.3389/fmed.2023.1251079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/10/2023] [Indexed: 08/08/2023] Open
Affiliation(s)
- Jun Teruya
- Transfusion Medicine and Coagulation, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Jean M. Connors
- Hematology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg im Breisgau, Germany
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22
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Yin EB. Anticoagulation Management in Temporary Mechanical Circulatory Support Devices. Tex Heart Inst J 2023; 50:e238135. [PMID: 37477030 PMCID: PMC10655856 DOI: 10.14503/thij-23-8135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Affiliation(s)
- Ellen B. Yin
- Department of Pharmacy, Baylor St Luke's Medical Center, Houston, Texas
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Tong Y, Rouzhahong J, Zhou W, Wang R, Wang Y, Ren Y, Guo J, Li Y, Wang Z, Song Y. Comparison of bivalirudin versus heparin in adult extracorporeal membrane oxygenation anticoagulant therapy: A retrospective case-control study. Int J Artif Organs 2023; 46:162-170. [PMID: 36600413 DOI: 10.1177/03913988221148763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION There were controversial opinions on the use of bivalirudin versus heparin for anticoagulant therapy in extracorporeal membrane oxygenation. The aim of our present study is to evaluate the efficacy and safety of bivalirudin versus heparin for the maintenance of systemic anticoagulation during adult veno-venous extracorporeal membrane oxygenation (V-V ECMO). METHODS Adult patients who received V-V ECMO support in our center between February 2018and February 2022 were retrospectively recruited. We analyzed their ECMO support time, platelet count, coagulation indicators, blood product infusion volume, the incidence of thrombosis and bleeding, probability of successful weaning of ECMO, and in-hospital mortality. RESULTS A total of 58 patients received V-V ECMO support. Thirty-four patients were finally included according to the exclusion and inclusion criteria, 14 and 20 accepted bivalirudin and heparin for anticoagulant therapy, respectively. The Minimum platelet value (98.50 × 109/L (85.50, 123.75) vs 49.50 × 109/L (31.25, 83.00), p = 0.002) and mean platelet value (149.90 × 109/L (127.40, 164.80) vs 74.55 × 109/L (62.45, 131.60), p = 0.03) and the ratio of successful weaning of ECMO (92.8% vs 60.0%, p = 0.033) in bivalirudin group were significantly higher than those in heparin group. The red blood cell infusion volume (7.00 U (3.00, 13.25) vs 13.75 U (7.25, 22.63), p = 0.039), platelet infusion volume (0.00 mL (0.00, 75.00) vs 300 mL (0.00, 825.00), p = 0.027), and the incidence of major bleeding (0.00% vs 30%, p = 0.024) in bivalirudin group were significantly lower than those in heparin group. CONCLUSIONS In V-V ECMO-supported adult patients, systemic anticoagulation with bivalirudin has achieved the same anticoagulation targets as heparin with less frequency of major bleeding events and lower requirement for blood products without significantly increased risk of thrombosis. Bivalirudin most likely is a safe and effective anticoagulation method for adult patients supported by V-V ECMO.
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Affiliation(s)
- Yaowei Tong
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Julaiti Rouzhahong
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Wangtao Zhou
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Rui Wang
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Yuqiang Wang
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Yucheng Ren
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Ju Guo
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Ying Li
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Zhengkai Wang
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Yunlin Song
- Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
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Buckley MS, Benanti GE, Meckel J, Tekle LA, Gilbert B, Puebla Neira D, McNierney DA, Korkames G, Yerondopoulos M, Park A, O'Hea JA, MacLaren R. Correlation between partial thromboplastin time and thromboelastography in adult critically ill patients requiring bivalirudin for extracorporeal membrane oxygenation. Pharmacotherapy 2023; 43:196-204. [PMID: 36759323 DOI: 10.1002/phar.2776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/29/2022] [Accepted: 12/30/2022] [Indexed: 02/11/2023]
Abstract
STUDY OBJECTIVE Thromboelastography (TEG) offers a more dynamic assessment of hemostasis over activated partial thromboplastin time (aPTT). However, the clinical utility of TEG in monitoring bivalirudin during extracorporeal membrane oxygenation (ECMO) remains unknown. The purpose of this study was to evaluate the correlation between aPTT and TEG in adult ECMO patients anticoagulated with bivalirudin. DESIGN Multicenter, retrospective, cohort study conducted over a 2-year period. SETTING Two academic university medical centers (Banner University Medical Center) in Phoenix and Tucson, AZ. PATIENTS Adult patients requiring ECMO and bivalirudin therapy with ≥1 corresponding standard TEG and aPTT plasma samples drawn ≤4 h of each other were included. The primary endpoint was to determine the correlation coefficient between the standard TEG reaction (R) time and bivalirudin aPTT serum concentrations. MEASUREMENTS AND MAIN RESULTS A total of 104 patients consisting of 848 concurrent laboratory assessments of R time and aPTT were included. A moderate correlation between TEG R time and aPTT was demonstrated in the study population (r = 0.41; p < 0.001). Overall, 502 (59.2%) concurrent assessments of TEG R time and aPTT values showed agreement on whether they were sub-, supra-, or therapeutic according to the institution's classification for bivalirudin. The 42.2% (n = 271/642) discordant TEG R times among "therapeutic" aPTT were almost equally distributed between subtherapeutic and supratherapeutic categories. CONCLUSIONS Moderate correlation was found between TEG R time and aPTT associated with bivalirudin during ECMO in critically ill adults. Further research is warranted to address the optimal test to guide clinical decision-making for anticoagulation dosing in ECMO patients.
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Affiliation(s)
- Mitchell S Buckley
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Grace E Benanti
- Department of Pharmacy, Loyola University Medical Center, Maywood, Illinois, USA
| | - Jordan Meckel
- Department of Pharmacy, Loyola University Medical Center, Maywood, Illinois, USA
| | - Luwam A Tekle
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Brian Gilbert
- Department of Pharmacy, Wesley Medical Center, Wichita, Kansas, USA
| | - Daniel Puebla Neira
- Department of Pulmonary and Critical Care, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Dakota A McNierney
- Department of Medicine, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Grace Korkames
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Melanie Yerondopoulos
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Andrew Park
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Jennifer A O'Hea
- Division of Pulmonary/Critical Care, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
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Costabel JP, Duronto E, Guetta J, Ceresetto J, Guardiani F, Fescina JP, Procopio G, Casey M, Higa C, Villareal R, Bonorino J, Lamelas P. [Use of parenteral anticoagulants in patients with coronary syndrome]. Medicina (B Aires) 2023; 83:948-965. [PMID: 38117714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
Anticoagulant treatment, together with antiplatelet therapy, plays an important role in the treatment of acute coronary syndromes. Its use is associated with a reduction in new ischemic events, stent thrombosis, and lower mortality. However, in clinical practice there is great heterogeneity in its use, leading to suboptimal results in treatment. This paper conducts a narrative review on the use of parenteral anticoagulants in patients with acute coronary syndromes, depending on the clinical scenario, as well as the revascularization strategy used and the bleeding risk. The different anticoagulant schemes available in acute coronary syndromes with and without segment ST elevation are addressed, based on the updated evidence. Finally, evidence-based strategies for risk stratification for bleeding and therapeutic management are developed.
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Affiliation(s)
- Juan P Costabel
- Servicio de Cardiología, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina. E-mail:
| | - Ernesto Duronto
- Servicio de Cardiología, Fundación Favaloro, Buenos Aires, Argentina
| | - Javier Guetta
- Servicio de Cardiología, Centro de Educación Medica e Investigaciones Clínicas Norberto Quirno (CEMIC), Buenos Aires, Argentina
| | - José Ceresetto
- Servicio de Cardiología, Hospital Británico, Buenos Aires, Argentina
| | | | - Juan P Fescina
- Servicio de Cardiología, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Gastón Procopio
- Servicio de Cardiología, Fundación Favaloro, Buenos Aires, Argentina
| | - Marcelo Casey
- Servicio de Cardiología, FLENI, Buenos Aires, Argentina
| | - Claudio Higa
- Servicio de Cardiología, Hospital Alemán, Buenos Aires, Argentina
| | | | - José Bonorino
- Servicio de Cardiología, Hospital Austral, Buenos Aires, Argentina
| | - Pablo Lamelas
- Servicio de Cardiología, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
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26
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Kaushik S, Derespina KR, Chandhoke S, Shah DD, Cohen T, Shlomovich M, Medar SS, Peek GJ. Use of bivalirudin for anticoagulation in pediatric extracorporeal membrane oxygenation (ECMO). Perfusion 2023; 38:58-65. [PMID: 34318718 DOI: 10.1177/02676591211034314] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
This study describes the use of bivalirudin in children on extracorporeal membrane oxygenation (ECMO). Pediatric patients receiving bivalirudin were compared to patients receiving heparin as the anticoagulant on ECMO. Data was collected for children under 18 years of age supported by ECMO from January 2016 to December 2019. Data collected included demographics, diagnosis, ECMO indication, type, and duration, indication for bivalirudin use, dose range, activated partial thromboplastin time (aPTT) levels, minor and major bleeding, hemolysis, and mortality. Forty pediatric patients received ECMO; eight received bivalirudin primarily for anticoagulation. The median age was 4 months (IQR 0.5, 92) in the heparin cohort, 0.6 months (IQR 0.0, 80.0) in the primary bivalirudin cohort. The indication for ECMO was respiratory in 5 patients (18%) in the heparin group versus 6 (75%) in the primary bivalirudin group, cardiac in 18 (67%) in heparin versus 1 (12.5%) in primary bivalirudin, and extracorporeal-cardiopulmonary resuscitation (E-CPR) in 4 (15%) in heparin versus 1 (12.5%) in primary bivalirudin. Bivalirudin was the initial anticoagulant for eight patients (66.6%) while three (25%) were switched due to concern for heparin-induced thrombocytopenia (HIT) and one (8%) for heparin resistance. The median time to achieve therapeutic aPTT was 14.5 hours compared to 12 hours in the heparin group. Sixty-five percent of aPTT values in the bivalirudin and 44% of values in the heparin group were in the therapeutic range in the first 7 days. Patients with primary bivalirudin use had significantly lower dose requirement at 12 (p = 0.003), 36 (p = 0.007), and 48 (p = 0.0002) hours compared to patients with secondary use of bivalirudin. One patient (12.5%) had major bleeding, and two patients (25%) required circuit change in the primary bivalirudin cohort. Bivalirudin may provide stable and successful anticoagulation in children. Further large, multicenter studies are needed to confirm these findings.
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Affiliation(s)
- Shubhi Kaushik
- Division of Pediatric Critical Care Medicine, Kravis Children's Hospital at Mount Sinai, New York, NY, USA
| | - Kim R Derespina
- Division of Pediatric Critical Care Medicine, Kravis Children's Hospital at Mount Sinai, New York, NY, USA
| | - Swati Chandhoke
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Dhara D Shah
- Department of Pharmacy, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Taylor Cohen
- Division of Cardiovascular Perfusion, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Mark Shlomovich
- Division of Pediatric Critical Care Medicine, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Shivanand S Medar
- Division of Pediatric Critical Care Medicine, Children's Hospital at Montefiore, Bronx, NY, USA.,Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Giles J Peek
- Congenital Heart Center, Shands Children's Hospital, University of Florida at Gainesville, Gainesville, FL, USA
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27
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Guo Y, Wang J, Wang Z, Li L, An J. Efficacy and safety of bivalirudin bridging enoxaparin versus fondaparinux in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention: evidence from a single-center study. Arch Med Sci 2023; 19:242-249. [PMID: 36817677 PMCID: PMC9897106 DOI: 10.5114/aoms/157287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/09/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION This study aims to compare the safety and efficacy of bivalirudin bridging enoxaparin versus fondaparinux in patients with acute myocardial infarction (AMI) who were undergoing primary percutaneous coronary intervention (PPCI). METHODS The study is a prospective, natural, and selective interventional trial based on real-world data for 482 AMI patients. RESULTS At the end of the follow-up, the two groups demonstrated similar major adverse cardiovascular and cerebrovascular events (MACCE) and bleeding rates. After propensity score matching (PSM), the fondaparinux group showed greater advantages in reducing MACCE and bleeding events. CONCLUSIONS The anticoagulation strategy of bivalirudin bridging fondaparinux seems to be superior to that of bivalirudin bridging enoxaparin in patients with AMI undergoing PPCI.
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Affiliation(s)
- Yanqing Guo
- Department of Cardiology, Shanxi Cardiovascular Hospital, Taiyuan, Shanxi, China
| | - Jingping Wang
- Department of Cardiology, Shanxi Cardiovascular Hospital, Taiyuan, Shanxi, China
| | - Zhixin Wang
- Department of Cardiology, Shanxi Cardiovascular Hospital, Taiyuan, Shanxi, China
| | - Li Li
- Department of Cardiology, Shanxi Cardiovascular Hospital, Taiyuan, Shanxi, China
| | - Jian An
- Department of Cardiology, Shanxi Cardiovascular Hospital, Taiyuan, Shanxi, China
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Wang ZD, Chen YX, Liu M, Li P, Liang XW, Zhu XZ, Xie WC, Liao W. Safety of Bivalirudin Combined with Ticagrelor in the Emergency PCI in Patients with Acute ST-Segment Elevation Myocardial Infarction. Clin Appl Thromb Hemost 2022; 28:10760296221077973. [PMID: 36520539 PMCID: PMC9768824 DOI: 10.1177/10760296221077973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE The present study aimed to investigate the application safety of bivalirudin combined with ticagrelor in the emergency percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). METHODS From October 1, 2018, to December 30, 2019, 210 patients with STEMI admitted to the Department of Cardiology who underwent emergency PCI were randomly divided into the bivalirudin group (group A, N = 105) and the unfractionated heparin group (group B, N = 105). Before the emergency PCI operation after admission, the loading dose of aspirin (300 mg) was given orally, and then 100 mg/d. At the same time, the loading dose of ticagrelor (180 mg) was administered orally, and then 90 mg/bid. The adverse events and the hemorrhage events 30 days after the operation were observed and recorded. RESULTS There were five hemorrhage cases in the bivalirudin group, with one case of secondary hemorrhage and four cases of mild hemorrhage. There were 14 hemorrhages in the unfractionated heparin group with one case of secondary hemorrhage and thirteen cases of mild hemorrhage. In terms of mild hemorrhage, the hemorrhage rate in the bivalirudin group was significantly lower than that in the unfractionated heparin group (3.8% vs. 12.4%, P = 0.040). One patient died in the unfractionated heparin group, while no deaths occurred in the bivalirudin group during the thirty days of follow-up. No myocardial infarction, revascularization, or stroke occurred in the two groups within 30 days after the operation. CONCLUSION Compared with unfractionated heparin combined with ticagrelor in patients with STEMI undergoing emergency PCI treatment, bivalirudin combined with ticagrelor could significantly reduce the occurrence of mild hemorrhage events, and it would not increase the incidence of MACE during the 30 days of follow-up.
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Affiliation(s)
- Zheng-Dong Wang
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China
| | - Yu-Xiang Chen
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China
| | - Ming Liu
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China
| | - Ping Li
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China,Ping Li, Department of Cardiology,Yulin First People's Hospital(The Sixth Affiliated Hospital of Guangxi Medical University), No.495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China.
| | - Xiang-Wen Liang
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China
| | - Xian-Zhang Zhu
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China
| | - Wen-Chao Xie
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China
| | - Wang Liao
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China
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Burša F, Sklienka P, Frelich M, Jor O, Ekrtová T, Máca J. Anticoagulation Management during Extracorporeal Membrane Oxygenation-A Mini-Review. Medicina (Kaunas) 2022; 58. [PMID: 36556985 DOI: 10.3390/medicina58121783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has been established as a life-saving technique for patients with the most severe forms of respiratory or cardiac failure. It can, however, be associated with severe complications. Anticoagulation therapy is required to prevent ECMO circuit thrombosis. It is, however, associated with an increased risk of hemocoagulation disorders. Thus, safe anticoagulation is a cornerstone of ECMO therapy. The most frequently used anticoagulant is unfractionated heparin, which can, however, cause significant adverse effects. Novel drugs (e.g., argatroban and bivalirudin) may be superior to heparin in the better predictability of their effects, functioning independently of antithrombin, inhibiting thrombin bound to fibrin, and eliminating heparin-induced thrombocytopenia. It is also necessary to keep in mind that hemocoagulation tests are not specific, and their results, used for setting up the dosage, can be biased by many factors. The knowledge of the advantages and disadvantages of particular drugs, limitations of particular tests, and individualization are cornerstones of prevention against critical events, such as life-threatening bleeding or acute oxygenator failure followed by life-threatening hypoxemia and hemodynamic deterioration. This paper describes the effects of anticoagulant drugs used in ECMO and their monitoring, highlighting specific conditions and factors that might influence coagulation and anticoagulation measurements.
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30
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Yu XF, Chen HW, Xu J, Xu QZ, Zhang XH, Li BB, Xu BL, Ma LK. Bivalirudin vs. heparin on a background of ticagrelor and aspirin in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: A multicenter prospective cohort study. Front Cardiovasc Med 2022; 9:932054. [PMID: 36386368 PMCID: PMC9649932 DOI: 10.3389/fcvm.2022.932054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 10/05/2022] [Indexed: 10/24/2023] Open
Abstract
OBJECTIVE Current guidelines recommend potent P2Y12 inhibitors such as ticagrelor over clopidogrel as part of the dual antiplatelet therapy (DAPT) after ST-segment elevation myocardial infarction (STEMI), irrespective of final management strategy. The aim of this multicenter prospective cohort study was to examine the efficacy and safety of bivalirudin with background ticagrelor and aspirin therapy in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI). METHODS A total of 800 patients with STEMI who were undergoing PPCI and receiving treatment with aspirin and ticagrelor from three Hospitals between April 2019 and September 2021 were included in this study. The patients were assigned, according to the perioperative anticoagulant, to the bivalirudin group (n = 456) or the heparin group (n = 344). In this study, the primary endpoint was 30-day net adverse clinical events (NACEs), a composite of major adverse cardiac or cerebral events (MACCEs, a composite of cardiac death, recurrent myocardial infarction, ischemia-driven target vessel revascularization, or stroke), or any bleeding as defined by the Bleeding Academic Research Consortium (BARC) definition (grades 1-5). RESULTS The patients were followed up for 30 days after PPCI. The incidence of NACE was significantly lower in the bivalirudin group than in the heparin group (11.2 vs. 16.0%, P = 0.042), and this significance was mainly a consequence of the reduction in BARC 1 bleeding events in the bivalirudin group compared to the heparin group (3.2 vs. 7.1%, P = 0.010). Results from multivariate Cox regression analysis showed that bivalirudin significantly reduced 30-day NACE (HR: 0.676, 95% CI: 0.462-0.990, P = 0.042) and BARC1 bleeding events (HR: 0.429, 95% CI: 0.222-0.830, P = 0.010). No significant between-group differences were observed for MACCE, all-cause mortality, cardiac death, recurrent myocardial infarction, stroke, target vessel revascularization, stent thrombosis, and BARC2-5 bleeding events at 30 days. CONCLUSION In patients with STEMI who were undergoing primary PCI and receiving treatment with aspirin and ticagrelor, bivalirudin was associated with decreased rates in NACE and minimal bleeding events without significant differences in the rates of MACCE or stent thrombosis when compared with heparin. Nevertheless, large randomized trials are warranted to confirm these observations. CLINICAL TRIAL REGISTRATION The trial was registered at the Chinese Clinical Trial Registry (ChiCTR, http://www.chictr.org.cn; identifier [ChiCTR1900022529]). Registered on 15 April 2019. Registration title: Effect of bivalirudin combined with ticagrelor in patients with ST-segment elevation myocardial infarction during primary percutaneous coronary intervention.
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Affiliation(s)
- Xiao-Fan Yu
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Hong-Wu Chen
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Jie Xu
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Qi-Zhi Xu
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Xiao-Hong Zhang
- Department of Cardiology, The First People's Hospital of Hefei City, Hefei, China
| | - Bin-Bin Li
- Department of Cardiology, The First People's Hospital of Hefei City, Hefei, China
| | - Bang-Long Xu
- Department of Cardiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Li-Kun Ma
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
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Frydman GH, Berger BM, Kostousov V, Bruzdovski K, Papageorgiou DP, Navaei A, Hui SR, Teruya J. Novel Coagulation Test Detects Anticoagulation Resistance and Is Associated With Thrombotic Events in Pediatric Patients Requiring Extracorporeal Membrane Oxygenation. Crit Care Explor 2022; 4:e0776. [PMID: 36311559 DOI: 10.1097/CCE.0000000000000776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Bivalirudin, an IV direct thrombin inhibitor, and unfractionated heparin (UFH) are frequently used anticoagulants in the pediatric critical care setting. An accurate, specific, point-of-care test to quantify and detect anticoagulation resistance is not currently available. This study evaluates the ability of a rapid (< 10 min), micro-volume (< 50 uL) coagulation test to detect and quantify the anticoagulation effect of bivalirudin and UFH using a functional, clot time endpoint in pediatric critical care patients. DESIGN Single-site retrospective laboratory sample analysis and chart review. SETTING A 105-bed pediatric and cardiac ICUs delivering extracorporeal membrane oxygenation. SUBJECTS Forty-one citrated, frozen, biobanked plasma specimens comprising 21 with bivalirudin and 20 with UFH from 15 anticoagulated pediatric patients were analyzed. Thirteen patients were on extracorporeal membrane oxygenation, one had a submassive pulmonary embolism, and one was on a left ventricular assist device. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS A Clotting Time Score (CTS) was derived on each sample. The CTS detected patients that had developed a pathologic clotting event with 100% sensitivity and 82% specificity compared with prothrombin time with 25% sensitivity/76% specificity and activated partial thromboplastin time with 0% sensitivity/0% specificity. Additionally, the CTS detected subtherapeutic anticoagulation in response to UFH in patients that were clinically determined to be UFH resistant requiring alternative anticoagulation with bivalirudin. CONCLUSIONS The CTS appears to be a clinically valuable indicator of coagulation status in patients treated with either UFH or bivalirudin. Results outside of the therapeutic range due to inadequate dosing or anticoagulation resistance appeared to be associated with clot formation. CTS testing may reduce the risk of anticoagulation-related complications via the rapid identification of patients at high risk for pathologic thrombotic events.
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Zhuang S, Tang Q, Chen P, Wang C, Liu G. Bivalirudin exerts antiviral activity against respiratory syncytial virus-induced lung infections in neonatal mice. Acta Pharm 2022; 72:415-25. [PMID: 36651544 DOI: 10.2478/acph-2022-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 01/26/2023]
Abstract
Respiratory syncytial virus (RSV) is the most common cause of small airways inflammation in the lungs (bronchiolitis) in neonates and immunocompromised adults. The deregulation of cellular and plasma components leads to increased morbidity and mortality. The activation of the clotting cascade plays a key role in the progression of disease severity during viral infection. The current investigation studied the effect of bivalirudin (BR) on the progression and cellular effects of RSV-induced infection in the neonatal mice model. Mice (5-7 days old) were inoculated intranasally with RSV with or without BR administration (2 mg kg-1 day-1, i.v.) for 2 weeks. Tissue histopathology, inflammatory signalling genes such as TLR, and cytokines were analyzed. The results showed pneumocytes exhibiting nuclear pyknosis, cellular infiltration in lung tissue and increased lung titers in RSV-infected mice compared to the control. Furthermore, RSV-infected mice demonstrated altered clotting parameters such as D-dimer, soluble thrombomodulin, and increased inflammatory cytokines IL-5, 6, IFN-γ, IL-13, and CXCL1. Additionally, the mRNA expression analysis displayed increased levels of IL-33, TLR3, and TLR7 genes in RSV-infected lung tissue. Further, to delineate the role of micro RNAs, the qRT-PCR analysis was done, and the results displayed an increase in miR-136, miR-30b, and let-7i. At the same time, the down-regulated expression of miR-221 in RSV-infected mice compared to the control. BR treatment reduced the cellular infiltration with reduced inflammatory cytokines and normalized clotting indices. Thus, the study shows that RSV infection induces specific changes in lung tissue and the clotting related signalling mechanism. Additionally, BR treatment significantly reduces bronchiolitis and prevents the severity of the infections suggesting that BR can possibly be used to reduce the viral-mediated infections in neonates.
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Abstract
Extracorporeal membrane oxygenation (ECMO) is a widely used technique to provide circulatory and/or respiratory support in critically ill patients. ECMO treatment usually necessitates systemic anticoagulation. Unfractionated Heparin (UFH) is a commonly used anticoagulant in patients on ECMO support. In situations where UFH is contraindicated, alternative anticoagulation strategies can be applied, such as the use of direct thrombin inhibitors (DTI). Bivalirudin and argatroban are the most widely used DTIs. In this report we give account of the current evidence regarding dosing, monitoring and complications associated with the use of these agents in ECMO dependent patients.
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Affiliation(s)
- Janos Geli
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Massimo Capoccia
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Dirk M Maybauer
- Department of Anaesthesia and Intensive Care, Philipps University, Marburg, Germany
| | - Marc O Maybauer
- Department of Anaesthesia and Intensive Care, Philipps University, Marburg, Germany.,Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, Australia.,Advanced Critical Care and Acute Circulatory Support, Nazih Zuhdi Transplant Institute, Integris Health, Oklahoma City, OK, USA.,Department of Medicine, Oklahoma State University Health Science Center, Tulsa, OK, USA
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Lázaro-García A, Martínez-Alfonzo I, Vidal-Laso R, Velasco-Rodríguez D, Tomás-Mallebrera M, González-Rodríguez M, Llamas-Sillero P. A journey through anticoagulant therapies in the treatment of left ventricular thrombus in post-COVID-19 heparin-induced thrombocytopenia: a case report. Hematology 2022; 27:318-321. [PMID: 35231200 DOI: 10.1080/16078454.2022.2043572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse drug reaction associated with thrombosis. Clinical scoring systems and the presence of anti-platelet factor 4 (anti-PF4)/heparin antibodies determine the diagnosis. CASE PRESENTATION A 57-year-old man who was treated with acenocoumarol due to a chronic left ventricular thrombus was admitted to the hospital for severe SARS-CoV-2 pneumonia and pulmonary embolism. The patient was started on bemiparin and discharged. Left lower limb acute arterial ischemia and thrombocytopenia were diagnosed 18 days later. Computed tomography angiography revealed a large left ventricular thrombus and multiple arterial thrombi. Left femoral-popliteal thromboembolectomy was performed. Anti-PF4/heparin antibodies confirmed an HIT diagnosis. Fondaparinux (7.5 mg/24 h) was initiated, but cardiac surgery was necessary. Bivalirudin was used during surgery, with an initial load (1.25 mg/kg) and maintenance infusion (2.5 mg/kg/h). The cardiac thrombus was extracted, but the patient experienced a postsurgical myocardial infarction. Percutaneous cardiovascular intervention (PCI) required a bivalirudin load (0.75 mg/kg) and maintenance infusion (1.75 mg/kg/h). No coronary lesions were detected, and argatroban was started afterwards (0.5 µg/kg/min). When the platelet count exceeded 100 × 109/L, acenocoumarol was initiated. Thereupon, acetylsalicylic acid (100 mg/24 h) was added. No other complications have been reported to date. CONCLUSION The clinical presentation of intraventricular and multiple arterial thrombi is remarkable. SARS-CoV-2 infection likely contributed to a hypercoagulable state. The management of patients with HIT undergoing cardiac surgery is challenging. If surgery cannot be delayed, then treatment with bivalirudin is recommended. Additionally, this drug is recommended for PCI. Bivalirudin is safe and well-tolerated in both procedures.
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Affiliation(s)
- Alberto Lázaro-García
- Hematology and Hemotherapy Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Inés Martínez-Alfonzo
- Hematology and Hemotherapy Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Rosa Vidal-Laso
- Hematology and Hemotherapy Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Diego Velasco-Rodríguez
- Hematology and Hemotherapy Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | | | | | - Pilar Llamas-Sillero
- Hematology and Hemotherapy Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
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35
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Li J, Liu X, Ma S, Na K, Qi Z, Xu Y, Qiu M, Han Y, Li Y. Effectiveness and safety of bivalirudin in elderly patients with coronary artery disease undergoing percutaneous coronary intervention: A real-world study. Catheter Cardiovasc Interv 2022; 99 Suppl 1:1448-1455. [PMID: 35077603 DOI: 10.1002/ccd.30099] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the effectiveness and safety of bivalirudin compared with heparin monotherapy in elderly patients undergoing percutaneous coronary intervention (PCI). BACKGROUND Bivalirudin is recommended for periprocedural use in patients undergoing PCI who are of high bleeding risk. However, its safe and efficacious use in elderly patients, a typical high bleeding risk cohort, in real world practice is yet to be reported. METHODS In this single center, real-world observational study, 4736 consecutive elderly patients who underwent PCI were enrolled. Of these, 1240 were treated with bivalirudin and 3496 with heparin according to the periprocedural anticoagulation strategies of PCI. The primary outcome was 12-month net adverse clinical events (NACE) defined as a composite of cardiac death, myocardial infarction, stroke, revascularization, or any bleeding. Propensity score matching (PSM) was used to balance baseline characteristics between groups. RESULTS After PSM, bivalirudin was found to be associated with lower rates of NACE (19.1% vs. 24.7%, p = 0.002), cardiac death (2.7% vs. 4.3%, p = 0.038), and any bleeding (10.0% vs. 12.9%, p = 0.023) compared to heparin monotherapy. No differences were found in the incidences of myocardial infarction, stroke, revascularization, stent thrombosis (0.1% vs. 0.1%, p = 1.000), and major bleedings (0.5% vs. 0.5%, p = 1.000) between the two patient groups. CONCLUSION In this real-world observational study, periprocedural use of bivalirudin in elderly patients who underwent PCI was associated with less cardiac death and any bleeding compared to heparin monotherapy, without increased risk of stent thrombosis.
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Affiliation(s)
- Jing Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.,Department of Cardiology, The Graduate School of Harbin Medical University, Harbin, China
| | - Xiying Liu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.,Shenyang Pharmaceutical University, Shenyang, China
| | - Sicong Ma
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Kun Na
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.,Shenyang Pharmaceutical University, Shenyang, China
| | - Zizhao Qi
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.,Department of Cardiology, The Graduate School of Harbin Medical University, Harbin, China
| | - Ying Xu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Miaohan Qiu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
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Li Y, Li J, Guan C, Su S, Wang Z, Liu H, Xu B, Yang W, Yang Y, Gao R, Yuan J, Zhao X. Impact of Diabetes Mellitus on One-Year Clinical Outcomes in Patients Anticoagulated with Bivalirudin Undergoing Elective Percutaneous Coronary Intervention. Clin Appl Thromb Hemost 2022; 28:10760296221113344. [PMID: 35942867 PMCID: PMC9373170 DOI: 10.1177/10760296221113344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Patients with diabetes mellitus (DM) are considered to
increase the risk of thrombosis and bleeding. However, whether DM is an
independent risk factor for events in patients anticoagulated with bivalirudin
during elective percutaneous coronary intervention (PCI) is not clear.
Methods: Patients anticoagulated with bivalirudin during
elective PCI from January 2017 to August 2018 in 3 centers were enrolled. The
primary endpoint of thrombotic events was major adverse cardiac and
cerebrovascular events (MACCE, including all-cause death, myocardial infarction,
ischemic revascularization, stent thrombosis, and stroke); the primary endpoint
of bleeding events was Bleeding Academic Research Consortium (BARC) 2, 3 or 5
bleeding. Results: 1152 patients were finally enrolled. After
one-year follow-up, 89 (7.7%) MACCE and 21 (1.8%) BARC 2, 3 or 5 bleeding
occurred. Multivariate Cox regression analysis showed DM was not an independent
risk factor for MACCE (hazard ratio [HR]: 1.029, 95% confidence interval [CI]:
0.674-1.573, P = .893), but peripheral artery disease (PAD)
history (HR: 2.200, 95%CI: 1.290-3.751, P = .004) was an
independent risk factor for MACCE. DM was not an independent risk factor for
BARC 2, 3 or 5 bleeding (HR: 0.732, 95%CI: 0.293-1.831,
P = .505), but PAD history (HR: 3.029, 95%CI: 1.102-8.332,
P = .032) and low hemoglobin level (HR = 0.972, 95%CI:
0.947-0.998, P = .036) were independent risk factors for BARC
2, 3 or 5 bleeding. Conclusions: DM was not an independent risk
factor for one-year thrombotic and bleeding events in patients anticoagulated
with bivalirudin during elective PCI. More attention should be paid to PAD
history and hemoglobin level to identify high-risk patients.
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Affiliation(s)
- Yulong Li
- National Clinical Research Center for Cardiovascular Diseases, State
Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for
Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union
Medical College, Beijing, China
| | - Jiawen Li
- National Clinical Research Center for Cardiovascular Diseases, State
Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for
Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union
Medical College, Beijing, China
| | - Changdong Guan
- National Clinical Research Center for Cardiovascular Diseases, State
Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for
Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union
Medical College, Beijing, China
| | - Shuhong Su
- Department of Cardiology, Xinxiang Central Hospital, Xinxiang,
China
| | - Zhifang Wang
- Department of Cardiology, Xinxiang Central Hospital, Xinxiang,
China
| | - Haiwei Liu
- Department of Cardiology, Northern Theatre General Hospital,
Shenyang, China
| | - Bo Xu
- National Clinical Research Center for Cardiovascular Diseases, State
Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for
Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union
Medical College, Beijing, China
| | - Weixian Yang
- National Clinical Research Center for Cardiovascular Diseases, State
Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for
Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union
Medical College, Beijing, China
| | - Yuejin Yang
- National Clinical Research Center for Cardiovascular Diseases, State
Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for
Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union
Medical College, Beijing, China
| | - Runlin Gao
- National Clinical Research Center for Cardiovascular Diseases, State
Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for
Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union
Medical College, Beijing, China
| | - Jinqing Yuan
- National Clinical Research Center for Cardiovascular Diseases, State
Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for
Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union
Medical College, Beijing, China
- Jinqing Yuan, National Clinical Research
Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular
Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese
Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi
Road, Xicheng District, Beijing 100037, China.
| | - Xueyan Zhao
- National Clinical Research Center for Cardiovascular Diseases, State
Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for
Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union
Medical College, Beijing, China
- Xueyan Zhao, National Clinical Research
Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular
Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese
Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi
Road, Xicheng District, Beijing 100037, China.
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Peng X, Li Z, Li D, Li Z, Lu Z, Luo C, Ji Z. Bivalirudin Presents a Favorable Safety Profile Regarding Adverse Drug Reactions, Thrombocytopenia, and Bleeding in Chinese Patients With High Bleeding Risk Undergoing Percutaneous Coronary Intervention: A Prospective, Multi-Center, Intensive Monitoring Study. Front Cardiovasc Med 2022; 9:821322. [PMID: 37168321 PMCID: PMC10166107 DOI: 10.3389/fcvm.2022.821322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/29/2022] [Indexed: 05/13/2023] Open
Abstract
Background This study aimed to comprehensively explore the occurrence and risk factors for adverse events (AEs) and adverse drug reactions (ADRs) (especially for thrombocytopenia and bleeding) in Chinese patients with high bleeding risk (older adults, or complicated with diabetes mellitus or renal function impairment) undergoing percutaneous coronary intervention (PCI) with bivalirudin as an anticoagulant. Methods A total of 1,226 patients with high bleeding risk who received PCI with bivalirudin as an anticoagulant from 27 Chinese medical centers were enrolled in this prospective, multi-center, intensive monitoring study. AEs, ADRs, thrombocytopenia, and bleeding were collected from admission to 72 h post-bivalirudin administration; subsequently, patients were followed up on the 30th day with the safety data collected as well. Results Adverse events were observed in 198 (16.2) patients, among which severe AEs occurred in 16 (1.3%) patients. Meanwhile, bivalirudin-related ADRs were reported in 66 (5.4%) patients, among which 5 (0.4%) patients experienced bivalirudin-related severe ADRs. Besides, thrombocytopenia and bleeding occurred in 45 (3.7%) and 19 (1.5%) patients, respectively. The subsequent multivariate logistic analysis revealed that age >75 years [p = 0.017, odds ratio (OR) = 1.856] and spontaneous coronary artery dissection (SCAD) (p = 0.030, OR = 2.022) were independently related to higher ADR risk; SCAD (p = 0.017, OR = 2.426) was independently correlated with higher thrombocytopenia risk, while radial artery access (p = 0.015, OR = 0.352) was independently correlated with lower thrombocytopenia risk; and the administration of bivalirudin preoperatively or intraoperatively (p = 0.013, OR = 5.097) was independently associated with higher bleeding risk. Conclusion Bivalirudin presents a favorable safety profile regarding ADRs, thrombocytopenia, and bleeding in Chinese patients with high bleeding risk undergoing PCI.
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Affiliation(s)
- Xiaoping Peng
- Department of Cardiovascular, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhenyong Li
- Department of Cardiology, Xuzhou Central Hospital, Xuzhou, China
| | - Dunheng Li
- Department of Cardiology, Tai’an First People’s Hospital, Tai’an, China
| | - Zhongyin Li
- Department of Cardiovascular, Puyang Oilfield General Hospital, Puyang, China
| | - Zhaohua Lu
- Department of Cardiology, Wuzhou People’s Hospital, Wuzhou, China
| | - Caidong Luo
- Department of Cardiology, Mianyang Central Hospital, Mianyang, China
- *Correspondence: Caidong Luo,
| | - Zheng Ji
- First Department of Cardiology, Tangshan Worker’s Hospital, Tangshan, China
- Zheng Ji,
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38
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James S, Koul S, Andersson J, Angerås O, Bhiladvala P, Calais F, Danielewicz M, Fröbert O, Grimfjärd P, Götberg M, Henareh L, Ioanes D, Jensen J, Linder R, Lindroos P, Omerovic E, Panayi G, Råmunddal T, Sarno G, Ulvenstam A, Völtz S, Wagner H, Wikström H, Östlund O, Erlinge D. Bivalirudin Versus Heparin Monotherapy in ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Interv 2021; 14:e008969. [PMID: 34903034 DOI: 10.1161/circinterventions.120.008969] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Bivalirudin was not superior to unfractionated heparin in patients with myocardial infarction (MI) treated with percutaneous coronary intervention and no planned use of GPI (glycoprotein IIb/IIIa inhibitors) in contemporary clinical practice of radial access and potent P2Y12-inhibitors in the VALIDATE-SWEDEHEART randomized clinical trial (Bivalirudin Versus Heparin in STEMI and NSTEMI Patients on Modern Antiplatelet Therapy-Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies Registry). METHODS In this prespecified separately powered subgroup analysis, we included patients with ST-segment-elevation MI undergoing primary percutaneous coronary intervention with the primary composite end point of all-cause death, MI, or major bleeding event within 180 days. RESULTS Among the 6006 patients enrolled in the trial, 3005 patients with ST-segment-elevation MI were randomized to receive bivalirudin or heparin. The mean age was 66.8 years. According to protocol recommendations, 87% were treated with potent oral P2Y12-inhibitors before start of angiography and radial access was used in 90%. GPI was used in 51 (3.4%) and 74 (4.9%) of patients randomized to receive bivalirudin and heparin, respectively. The primary end point occurred in 12.5% (187 of 1501) and 13.0% (196 of 1504; hazard ratio [HR], 0.95 [95% CI, 0.78-1.17], P=0.64) with consistent results in all major subgroups. All-cause death occurred in 3.9% versus 3.9% (HR, 1.00 [0.70-1.45], P=0.98), MI in 1.7% versus 2.2% (HR, 0.76 [0.45-1.28], P=0.30), major bleeding in 8.3% versus 8.0% (HR, 1.04 [0.81-1.33], P=0.78), and definite stent thrombosis in 0.5% versus 1.3% (HR, 0.42 [0.18-0.96], P=0.04). CONCLUSIONS In patients with ST-segment-elevation MI undergoing primary percutaneous coronary intervention with radial access and receiving current recommended treatments with potent P2Y12-inhibitors rate of the composite of all-cause death, MI, or major bleeding was not lower in those randomized to receive bivalirudin as compared with heparin. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02311231.
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Affiliation(s)
- Stefan James
- Department of Medical Sciences (S.J., G.S.), Uppsala University, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Sweden (S.K., P.B., M.G., D.E.)
| | | | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (O.A., D.I., E.O., T.R., S.V.)
| | - Pallonji Bhiladvala
- Department of Cardiology, Clinical Sciences, Lund University, Sweden (S.K., P.B., M.G., D.E.)
| | - Fredrik Calais
- Department of Cardiology, Faculty of Health, Örebro University, Sweden (F.C., O.F.)
| | | | - Ole Fröbert
- Department of Cardiology, Faculty of Health, Örebro University, Sweden (F.C., O.F.)
| | - Per Grimfjärd
- Department of Internal Medicine, Västmanlands Sjukhus, Västerås, Sweden (P.G.)
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Sweden (S.K., P.B., M.G., D.E.)
| | - Loghman Henareh
- Department of Cardiology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden (L.H.)
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (O.A., D.I., E.O., T.R., S.V.)
| | - Jens Jensen
- Department of Cardiology, Capio St Görans Hospital AB, Stockholm, Sweden (J.J., P.L.)
| | - Rikard Linder
- Department of Cardiology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (R.L.)
| | - Pontus Lindroos
- Department of Cardiology, Capio St Görans Hospital AB, Stockholm, Sweden (J.J., P.L.)
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (O.A., D.I., E.O., T.R., S.V.)
| | - Georgios Panayi
- Department of Cardiology, Linköping University, Sweden (G.P.)
| | - Truls Råmunddal
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (O.A., D.I., E.O., T.R., S.V.)
| | - Giovanna Sarno
- Department of Medical Sciences (S.J., G.S.), Uppsala University, Sweden
| | | | - Sebastian Völtz
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (O.A., D.I., E.O., T.R., S.V.)
| | - Henrik Wagner
- Department of Cardiology, Helsingborg Lasarett, Sweden (H. Wagner)
| | - Helena Wikström
- Department of Cardiology, Kristianstad Hospital, Sweden (H. Wikström)
| | - Ollie Östlund
- Uppsala Clinical Research Center (O.Ö.), Uppsala University, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Sweden (S.K., P.B., M.G., D.E.)
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39
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Li S, Lv D, Liu C, Jia Y. Practicability of Bivalirudin plus Glycoprotein IIb/IIIa Inhibitors in Patients Undergoing Percutaneous Coronary Intervention: A Meta-Analysis. Clin Appl Thromb Hemost 2021; 27:10760296211055165. [PMID: 34775846 PMCID: PMC8597062 DOI: 10.1177/10760296211055165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A variety of antithrombotic drugs are used during percutaneous coronary interventions (PCIs). We aimed to investigate the practicability of the use of bivalirudin and GPIs in patients receiving PCI. We searched 7 of 629 relevant records from PubMed, the Cochrane Library, EMBASE, and Web of Science for randomised controlled trials. There were no significant differences in the rates of major adverse cardiac events (MACE) between bivalirudin plus GPI and heparin (all P > .05). Bivalirudin plus planned GPI was similar to bivalirudin monotherapy in terms of the risk of MACE (risk ratio [RR] = 1.07; 95% confidence interval [CI] = .91 − 1.27; P = .55). Bivalirudin plus provisional GPI was associated with lower bleeding risk (RR = .57; 95% CI = .47 − .69; P < .01) compared to using heparin plus GPI. Compared to bivalirudin alone, bivalirudin plus planned GPI evidently increased bleeding risk (RR = 2.20; 95% CI = 1.73 − 2.79; P < .01). Patients receiving bivalirudin or heparin therapy had semblable efficacy endpoints, but those receiving bivalirudin had a significantly lower bleeding risk. For high-risk bleeding patients, bivalirudin plus provisional GPI can have a better antithrombotic effect than heparin, without increasing the bleeding risk.
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Affiliation(s)
- Senjie Li
- 105862Department of Cardiology, The First Hospital of ShanXi Medical University, Taiyuan, Shanxi, China
| | - Dongqing Lv
- 105862Department of Endocrinology, The First Hospital of ShanXi Medical University, Taiyuan, Shanxi, China
| | - Caihong Liu
- 74648ShanXi Medical University, Taiyuan, Shanxi, China
| | - Yongping Jia
- 105862Department of Cardiology, The First Hospital of ShanXi Medical University, Taiyuan, Shanxi, China
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40
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Razuk V, Camaj A, Cao D, Nicolas J, Hengstenberg C, Sartori S, Zhang Z, Power D, Beerkens F, Chiarito M, Meneveau N, Tron C, Dumonteil N, Widder JD, Ferrari M, Violini R, Stella PR, Jeger R, Anthopoulos P, Mehran R, Dangas GD. Impact of anemia on short-term outcomes after TAVR: A subgroup analysis from the BRAVO-3 randomized trial. Catheter Cardiovasc Interv 2021; 98:E870-E880. [PMID: 33909348 DOI: 10.1002/ccd.29753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 04/26/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To determine the prognostic impact of anemia in patients randomized to bivalirudin or unfractionated heparin (UFH) during transcatheter aortic valve replacement (TAVR). BACKGROUND Whether the periprocedural use of bivalirudin as compared with UFH in anemic patients undergoing TAVR has an impact on outcomes remains unknown. METHODS The BRAVO-3 trial compared the use of bivalirudin versus UFH in 802 high risk patients undergoing transfemoral TAVR for severe symptomatic aortic stenosis. Patients were stratified according to the presence (defined as hemoglobin levels <13 g/dl in men and <12 g/dl in women) or absence of anemia. The primary outcomes were net adverse cardiac events (NACE; a composite of all-cause mortality, myocardial infarction, stroke, or bleeding) and major bleeding (Bleeding Academic Research Consortium ≥3b) at 30 days. RESULTS Among 798 patients with available baseline hemoglobin levels, 427 (54%) were anemic of whom 221 (52%) received bivalirudin. There were no significant differences in NACE and major bleeding at 30 days between patients with and without anemia, irrespective of the type of anticoagulant used (pinteraction = 0.71 for NACE, pinteraction = 1.0 for major bleeding). However, anemic patients had a higher risk of major vascular complications (adjusted OR 2.43, 95% CI 1.42-4.16, p = 0.001), and acute kidney injury (adjusted OR 1.74, 95% CI 1.16-2.59, p = 0.007) compared to non-anemic patients at 30 days. CONCLUSIONS Anemia was not associated with a higher risk of NACE or major bleeding at 30 days after TAVR without modification of the treatment effects of periprocedural anticoagulation with bivalirudin versus UFH.
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Affiliation(s)
- Victor Razuk
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anton Camaj
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christian Hengstenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David Power
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Frans Beerkens
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mauro Chiarito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France
| | - Christophe Tron
- Division of Cardiology, Rouen University Hospital, Rouen, France
| | - Nicolas Dumonteil
- Groupe CardioVasculaire Interventionnel, Clinique Pasteur, Toulouse, France
| | - Julian D Widder
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Markus Ferrari
- Interventional Cardiology, Helios Dr. Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Germany
| | - Roberto Violini
- Interventional Cardiology Unit, San Camillo Hospital, Rome, Italy
| | - Pieter R Stella
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Raban Jeger
- Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | | | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Fu D, Liu M, Gao T, Li C, Liao J, Shao M, Xiao X, Yang P, Li X, Jiang H. Evaluation of Bivalirudin-Associated Major Adverse Cardiac and Hemorrhagic Events in Acute Coronary Syndrome Patients on Chronic Dialysis Following Percutaneous Coronary Intervention. J Invasive Cardiol 2021; 33:E877-E883. [PMID: 34653957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND AIM Patients with chronic dialysis dependency undergoing percutaneous coronary intervention (PCI) are at a greater risk of hemorrhagic and ischemic events. Due to their exclusion from randomized clinical trials, the optimal antithrombotic regimen for this population remains unknown. Bivalirudin has been associated with fewer hemorrhagic complications than unfractionated heparin (UFH) in patients undergoing PCI. We evaluated major adverse cardiac event (MACE) and hemorrhagic event rates for an antithrombotic regimen using bivalirudin or UFH during PCI in acute coronary syndrome (ACS) patients with chronic dialysis dependency. METHODS A retrospective study was performed, including 211 patients on dialysis undergoing PCI due to ACS from January 2014 to April 2019 at the China-Japan Friendship Hospital. Patients were divided into 2 groups based on anticoagulation regimen: the bivalirudin group (86 cases) or the UFH group (125 cases) during and after PCI. Statistical analyses were used to compare MACE and hemorrhagic events between groups at 30 days after PCI. RESULTS No patients experienced stent thrombosis within 30 days after PCI regardless of anticoagulant. There was no difference in the incidence of MACE in the bivalirudin group compared with the UFH group (6.98% vs 8.80%, respectively; P>.05). The rate of hemorrhagic events in the bivalirudin group was significantly lower than in the UHP group (5.81% vs 18.4%, respectively; P<.05), particularly for rates of mild bleeding (4.65% vs 15.2%, respectively; P<.05). There were no significant differences in rates of severe bleeding between the bivalirudin and UFH groups (1.16% vs 4.00%, respectively; P>.05), although fewer severe hemorrhagic events occurred in the bivalirudin group. CONCLUSION Bivalirudin was associated with fewer bleeding events following PCI in individuals with end-stage renal disease on dialysis.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Hong Jiang
- China-Japan Friendship Hospital, Yinghua Dongjie 2, Chaoyang District, Beijing 100029, China.
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Lund M, Macwan AS, Tunströmer K, Lindahl TL, Boknäs N. Effects of Heparin and Bivalirudin on Thrombin-Induced Platelet Activation: Differential Modulation of PAR Signaling Drives Divergent Prothrombotic Responses. Front Cardiovasc Med 2021; 8:717835. [PMID: 34660719 PMCID: PMC8511449 DOI: 10.3389/fcvm.2021.717835] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/06/2021] [Indexed: 11/13/2022] Open
Abstract
Heparin and bivalirudin are widely used as anticoagulants in the setting of acute thrombosis. In this study, we investigated how these drugs affect the ability of thrombin to generate a prothrombotic platelet response via activation of the protease-activated receptors (PARs) 1 and 4. We examined the effects of heparin/antithrombin and bivalirudin on PAR1- and PAR4-mediated intracellular calcium mobilization, aggregation, α-granule release, and procoagulant membrane exposure in platelets exposed to thrombin concentrations likely to be encountered in the thrombus microenvironment during thrombosis. At physiological antithrombin levels, heparin treatment resulted in complete and sustained inhibition of thrombin-induced PAR4-mediated platelet activation, but transient PAR1 signaling was sufficient to elicit significant α-granule release and platelet aggregation. In contrast, bivalirudin treatment resulted in rapid and profound inhibition of signaling from both PAR receptors, followed by a delayed phase of PAR4-mediated platelet activation, resulting in a robust prothrombotic response. Combination treatment with bivalirudin and subtherapeutic concentrations of heparin completely inhibited the residual platelet activation observed with single drug treatment at all time-points. Our results show that heparin and bivalirudin have different and complementary inhibitory effects on the activation of PAR1 and PAR4 by thrombin.
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Affiliation(s)
- Mikael Lund
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ankit S Macwan
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Kjersti Tunströmer
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Tomas L Lindahl
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Clinical Chemistry and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Niklas Boknäs
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Hematology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Du P, Li X, Sun L, Pan Y, Zhu H, Li Y, Yang Y, Wei X, Jing C, Chen H, Shi Q, Li W, Zhao L. Improved hemocompatibility by modifying acellular blood vessels with bivalirudin and its biocompatibility evaluation. J Biomed Mater Res A 2021; 110:635-651. [PMID: 34599549 DOI: 10.1002/jbm.a.37316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/14/2021] [Accepted: 09/22/2021] [Indexed: 11/08/2022]
Abstract
The incidence rate of cardiovascular diseases is increasing year by year. The demand for coronary artery bypass grafting has been very large. Acellular blood vessels have potential clinical application because of their natural vascular basis, but their biocompatibility and anticoagulant energy need to be improved. We decellularized the abdominal aorta of SD rats, and then modified with bivalirudin via polydopamine. The mechanical properties, blood compatibility, cytocompatibility, immune response, and anticoagulant properties were evaluated, and then the bivalirudin-modified acellular blood vessels were implanted into rats for remodeling evaluation in vivo. The results we got show that the bivalirudin-modified acellular blood vessels showed good cytocompatibility and blood compatibility, and its anti-inflammatory trend was dominant in the immune response. After 3 months of transplantation, the bivalirudin-modified acellular blood vessels did not easily form thrombus. It was not easy to form calcification and could make the host cells grow better. Through vascular stimulation and immunofluorescence test, we found that vascular smooth muscle cells and endothelial cells proliferated well in the bivalirudin group. Bivalirudin-modified acellular blood vessels provided new idea for small diameter tissue engineering blood vessels, and may become a potential clinical substitute for small-diameter vascular grafts.
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Affiliation(s)
- Pengchong Du
- Key Laboratory of Cardiac Structure Research, Zhengzhou Seventh People's Hospital, College of Life Science and Technology, Xinxiang Medical University, Xinxiang, China.,Department of Cardiothoracic Surgery, Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Xiafei Li
- College of Medical Engineering, Xinxiang Medical University, Xinxiang, China
| | - Lulu Sun
- Key Laboratory of Cardiac Structure Research, Zhengzhou Seventh People's Hospital, College of Life Science and Technology, Xinxiang Medical University, Xinxiang, China
| | - Yuxue Pan
- Key Laboratory of Cardiac Structure Research, Zhengzhou Seventh People's Hospital, College of Life Science and Technology, Xinxiang Medical University, Xinxiang, China
| | - Hengchao Zhu
- Key Laboratory of Cardiac Structure Research, Zhengzhou Seventh People's Hospital, College of Life Science and Technology, Xinxiang Medical University, Xinxiang, China
| | - Yangyang Li
- Department of Cardiothoracic Surgery, Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Yingjie Yang
- Department of Cardiothoracic Surgery, Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Xieze Wei
- Department of Anesthesiology, Xinxiang Central Hospital of Xinxiang Medical University, Xinxiang, China
| | - Changqin Jing
- Key Laboratory of Cardiac Structure Research, Zhengzhou Seventh People's Hospital, College of Life Science and Technology, Xinxiang Medical University, Xinxiang, China
| | - Hongli Chen
- Key Laboratory of Cardiac Structure Research, Zhengzhou Seventh People's Hospital, College of Life Science and Technology, Xinxiang Medical University, Xinxiang, China
| | - Qizhong Shi
- Department of Cardiothoracic Surgery, Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Wenbin Li
- Department of Cardiothoracic Surgery, Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Liang Zhao
- Key Laboratory of Cardiac Structure Research, Zhengzhou Seventh People's Hospital, College of Life Science and Technology, Xinxiang Medical University, Xinxiang, China
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Giorni C, Rizza A, Favia I, Amodeo A, Chiusolo F, Picardo SG, Luciani M, Di Felice G, Di Chiara L. Pediatric Mechanical Circulatory Support: Pathophysiology of Pediatric Hemostasis and Available Options. Front Cardiovasc Med 2021; 8:671241. [PMID: 34540910 PMCID: PMC8440876 DOI: 10.3389/fcvm.2021.671241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/17/2021] [Indexed: 01/01/2023] Open
Abstract
Pediatric mechanical circulatory support (MCS) is considered a strategy for heart failure management as a bridge to recovery and transplantation or as a destination therapy. The final outcome is significantly impacted by the number of complications that may occur during MCS. Children on ventricular assist devices (VADs) and extracorporeal membrane oxygenation (ECMO) are at high risk for bleeding and thrombotic complications that are managed through anticoagulation. The first detailed guideline in pediatric VADs (Edmonton Anticoagulation and Platelet Inhibition Protocol) was based on conventional antithrombotic drugs, such as unfractionated heparin (UFH) and warfarin. UFH is the first-line anticoagulant in pediatric MCS, although its profile is not considered optimal in pediatric setting. The broad variation in heparin doses among children is associated with frequent occurrence of cerebrovascular accidents, bleeding, and thrombocytopenia. Direct thrombin inhibitors (DTIs) have been utilized as alternative strategies to heparin. Since 2018, bivalirudin has become the chosen anticoagulant in the long-term therapy of patients undergoing MCS implantation, according to the most recent protocols shared in North America. This article provides a review of the non-traditional anticoagulation strategies utilized in pediatric MCS, focusing on pharmacodynamics, indications, doses, and monitoring aspects of bivalirudin. Moreover, it exposes the efforts and the collaborations among different specialized centers, which are committed to an ongoing learning in order to minimize major complications in this special pediatric population. Further prospective trials regarding DTIs in a pediatric MCS setting are necessary and in specific well-designed randomized control trials between UFH and bivalirudin. To conclude, based on the reported literature, the clinical use of the bivalirudin in pediatric MCS seems to be a value added in controlling and maybe reducing thromboembolic complications. Further research is necessary to confirm all the results provided by this literature review.
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Affiliation(s)
- Chiara Giorni
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Alessandra Rizza
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Isabella Favia
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Antonio Amodeo
- Mechanical Circulatory Support Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Fabrizio Chiusolo
- Department of Anesthesia and Critical Care, Anestesia Rianimazione Comparto Operatorio, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Sergio G Picardo
- Department of Anesthesia and Critical Care, Anestesia Rianimazione Comparto Operatorio, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Matteo Luciani
- Department of Oncohematology, Haemostasis and Thrombosis Center, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Giovina Di Felice
- Hemostasis Laboratory, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Luca Di Chiara
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
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Ye H, Zhang Y, Huang Y, Li B, Cao R, Dai L, Huang B, Tian P, Li L, Han Y. Bivalirudin Attenuates Thrombin-Induced Endothelial Hyperpermeability via S1P/S1PR2 Category: Original Articles. Front Pharmacol 2021; 12:721200. [PMID: 34413778 PMCID: PMC8369898 DOI: 10.3389/fphar.2021.721200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 07/23/2021] [Indexed: 12/02/2022] Open
Abstract
Aims: To explore the role of the Sphingosine 1-Phosphate (S1P)/Receptor2 (S1PR2) pathway in thrombin-induced hyperpermeability (TIP) and to test whether bivalirudin can reverse TIP via the S1P-S1PRs pathway. Methods and Results: Using western blot, we demonstrated that Human umbilical vein endothelial cells (HUVECs) that were cultured with 2 U/ml thrombin showed significantly increased S1PR2 expression while S1PR1and three kept unchanged. Such increment was attenuated by JTE-013 pretreatment and by presence of bivalirudin. Exposure of 2 U/ml of thrombin brought a higher level of S1P both intracellularly and extracellularly within the HUVECs by using ELISA detecting. Thrombin induced S1P and S1PR2 increment was restored by usage of PF543 and bivalirudin. Bivalirudin alone did not influenced the level of S1P and S1PR1,2, and S1PR3 compare to control group. As a surrogate of cytoskeleton morphology, phalloidin staining and immunofluorescence imaging were used. Blurry cell edges and intercellular vacuoles or spaces were observed along thrombin-exposed HUVECs. Presence of JTE-013 and bivalirudin attenuated such thrombin-induced permeability morphological change and presence of heparin failed to show the protective effect. Transwell chamber assay and probe assay were used to measure and compare endothelial permeability in vitro. An increased TIP was observed in HUVECs cultured with thrombin, and coculture with bivalirudin, but not heparin, alleviated this increase. JTE-013 treatment yielded to similar TIP alleviating effect. In vivo, an Evans blue assay was used to test subcutaneous and organ microvascular permeability after the treatment of saline only, thrombin + saline, thrombin + bivalirudin, thrombin + heparin or thrombin + JTE-013. Increased subcutaneous and organ tissue permeability after thrombin treatment was observed in thrombin + saline and thrombin + heparin groups while treatment of bivalirudin and JTE-013 absent this effect. Conclusion: S1P/S1PR2 mediates TIP by impairing vascular endothelial barrier function. Unlike heparin, bivalirudin effectively blocked TIP by inhibiting the thrombin-induced S1P increment and S1PR2 expression, suggesting the novel endothelial protective effect of bivalirudin under pathological procoagulant circumstance.
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Affiliation(s)
- Haowen Ye
- Department of Cardiology, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Yizhi Zhang
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yihui Huang
- Department of Pediatrics, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Biao Li
- Department of Cardiology, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Ruhao Cao
- Department of Cardiology, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Libing Dai
- Guangzhou Institute of Traumatic Surgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Bin Huang
- Department of Cardiology, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Pingge Tian
- Department of Cardiology, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Li Li
- Department of Cardiology, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Yaling Han
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
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Giuliano K, Bigelow BF, Etchill EW, Velez AK, Ong CS, Choi CW, Bush E, Cho SM, Whitman GJR. Extracorporeal Membrane Oxygenation Complications in Heparin- and Bivalirudin-Treated Patients. Crit Care Explor 2021; 3:e0485. [PMID: 34278315 DOI: 10.1097/CCE.0000000000000485] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: Extracorporeal membrane oxygenation is a potentially life-saving intervention in refractory cardiopulmonary failure, but it requires anticoagulation to prevent circuit thromboses, which exposes the patient to hemorrhagic complications. Heparin has traditionally been the anticoagulant of choice, but the direct thrombin inhibitor bivalirudin is routinely used in cases of heparin-induced thrombocytopenia and has been suggested as a superior choice. We sought to examine the timing of hemorrhagic and thrombotic complications after extracorporeal membrane oxygenation cannulation and to compare the rates of such complications between patients anticoagulated with heparin versus bivalirudin. DESIGN: Retrospective cohort study. SETTING: Johns Hopkins Hospital patients between January 2016 and July 2019. PATIENTS: Adult (> 18 yr) extracorporeal membrane oxygenation patients. INTERVENTIONS: Patients were anticoagulated either with heparin or bivalirudin. MEASUREMENTS AND MAIN RESULTS: We compared rates of hemorrhagic and thrombotic complications by time on heparin versus bivalirudin and characterized the average time to each complication. Of 144 extracorporeal membrane oxygenation patients (mean age 55.3 yr; 58% male), 41% were on central venoarterial extracorporeal membrane oxygenation, 40% on peripheral venoarterial extracorporeal membrane oxygenation, and 19% on venovenous extracorporeal membrane oxygenation. Thirteen patients (9%) received bivalirudin during their extracorporeal membrane oxygenation run, due to concern for (n = 8) or diagnosis of (n = 4) heparin-induced thrombocytopenia or for heparin resistance (n = 1). The rate of hemorrhagic or thrombotic complications did not differ between heparin (0.13/d) and bivalirudin (0.06/d; p = 0.633), but patients on bivalirudin received significantly fewer blood transfusions (1.0 U of RBCs/d vs 2.9/d on heparin; p < 0.001). CONCLUSIONS: Our results confirm the safety and efficacy of bivalirudin as an alternative anticoagulant in extracorporeal membrane oxygenation and suggest a potential benefit in less blood product transfusion, although prospective studies are needed to evaluate the true effect of bivalirudin versus the disease processes that prompted its use in our study population.
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Garcia-Garcia HM, Picchi A, Sardella G, Adamo M, Frigoli E, Limbruno U, Rigattieri S, Diletti R, Boccuzzi G, Zimarino M, Contarini M, Russo F, Calabro' P, Andò G, Varbella F, Garducci S, Palmieri C, Briguori C, Kuku KO, Rothenbühler M, Karagiannis A, Valgimigli M. Comparison of intra-procedural vs. post-stenting prolonged bivalirudin infusion for residual thrombus burden in patients with ST-segment elevation myocardial infarction undergoing: the MATRIX (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and angioX) OCT study. Eur Heart J Cardiovasc Imaging 2021; 20:1418-1428. [PMID: 30920584 DOI: 10.1093/ehjci/jez040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 02/25/2019] [Indexed: 11/14/2022] Open
Abstract
AIMS To compare prolonged bivalirudin infusion vs. an intra-procedural only bivalirudin infusion administration in subjects with ST-segment elevation myocardial infarction (STEMI) regarding residual stent strut thrombosis. METHODS AND RESULTS Multivessel STEMI patients undergoing primary percutaneous coronary intervention (PPCI) and scheduled for a staged percutaneous coronary intervention (PCI) before hospital discharge were selected among those allocated to either prolonged bivalirudin or intra-procedural only bivalirudin infusion in the MATRIX (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and angioX) Treatment-Duration study. Optical coherence tomography (OCT) of the infarct-related artery was performed at the end of PPCI and 4-5 days thereafter during staged intervention. The predefined endpoint was the percentage difference in the number of stent cross-sections with a thrombotic area >5% at the end of PPCI and at the time of staged PCI (ΔThCS). Between September 2013 and November 2015, 137 were randomized to either intra-procedural only bivalirudin infusion (N = 64) or prolonged bivalirudin (N = 73) at 16 European sites. Mean stent area, minimum lumen area, percentage of malapposed struts, and mean percent thrombotic area were comparable after index or staged PCI. The difference in the proportion of frames with percent thrombotic area >5% (ΔTh > 5%) were -7.7 (-22.1 to 5.1) in the intra-procedural bivalirudin infusion group and -8.8 (-23.1 to 2.6) in the prolonged infusion group (P = 0.994). Time from index to follow-up OCT imaging and the infarct vessel artery did not affect this OCT-based endpoint. CONCLUSION A strategy of prolonged bivalirudin infusion after PPCI did not reduce residual stent strut thrombosis when compared with intra-procedural only bivalirudin infusion administration (funded by The Medicines Company and Terumo; MATRIX ClinicalTrials.gov number, NCT01433627).
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Affiliation(s)
| | | | | | | | - Enrico Frigoli
- Clinical Trials Unit, University of Bern, Bern, Switzerland
| | | | | | - Roberto Diletti
- Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Marco Zimarino
- Università degli Studi "G. d'Annunzio" Chieti e Pescara, Chieti, Italy
| | | | | | - Paolo Calabro'
- Division of Cardiology, Department of Cardiothoracic and Respiratory Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giuseppe Andò
- Azienda Ospedaliera Universitaria G. Martino, Messina, Italy
| | | | - Stefano Garducci
- Unita' Operativa Complessa di Cardiologia ASST di Vimercate (MB), Vimercate, Italy
| | - Cataldo Palmieri
- Institute of Clinical Physiology, C.N.R./G. Monasterio Foundation, Massa, Italy
| | | | | | | | | | - Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University Hospital, Freiburgstrasse 8, Bern, Switzerland
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Wolstencroft P, Arnold P, Anderson BJ. Dose estimation for bivalirudin during pediatric cardiopulmonary bypass. Paediatr Anaesth 2021; 31:637-643. [PMID: 33423355 DOI: 10.1111/pan.14125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/15/2020] [Accepted: 01/05/2021] [Indexed: 01/19/2023]
Abstract
AIM A typical adult-based bivalirudin regimen during cardiopulmonary bypass uses a loading dose of 1 mg kg-1 and a circuit prime (volume L × 13 mg) with a subsequent intravenous infusion 2.5 mg h-1 kg-1 . Dose in children remains unknown. We wished to determine a practical bivalirudin dosing schedule for children undergoing surgery with cardiopulmonary bypass. METHODS Published pharmacokinetic parameters in children who were anticoagulated for cardiac catheterization using bivalirudin were compared to adult by scaling for size using allometry. An infusion regimen suitable for children was determined using a bivalirudin target concentration (13 mg L-1 ) common in adults for effect during cardiopulmonary bypass. Predicted bivalirudin infusion rates in children were compared to regimens published as case reports. RESULTS Current pediatric bivalirudin infusion rates are based on those used in adults with titration during cardiopulmonary bypass to achieve activated clotting times longer than 400 s. Bivalirudin clearance (mL min-1 kg-1 ) can be estimated in children by scaling adult parameters using allometry. Clearance decreases through childhood and higher infusion rates in children would achieve target concentration rapidly without the need to titrate initial infusion rate. An infusion rate of 4.5 mg h-1 kg-1 in a 10 kg infant, 4 mg h-1 kg-1 in a 20 kg child and 3.5 mg h-1 kg-1 in a child 30-40 kg will target an activated clotting time slower than 400 s. Adult regimens could be used in those children heavier than 50 kg. CONCLUSION Bivalirudin infusion in children should be started after loading dose at rates greater than those used in adults. Dose in neonates remains uncertain because neither pharmacokinetics nor coagulation pharmacodynamics have been adequately characterized.
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Affiliation(s)
- Philip Wolstencroft
- Department of Paediatric Anaesthesia, Starship Children's Hospital, Auckland, New Zealand
| | - Philip Arnold
- Jackson Rees Department of Paediatric Anaesthesia, Alder Hey Children's Hospital, Liverpool, UK
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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Sun KX, Cui B, Cao SS, Wang WJ, Yu F, Wang JW, Ding Y. A meta-analysis and cost-minimization analysis of bivalirudin versus heparin in high-risk patients for percutaneous coronary intervention. Pharmacol Res Perspect 2021; 9:e00774. [PMID: 33939886 PMCID: PMC8092421 DOI: 10.1002/prp2.774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Indexed: 11/12/2022] Open
Abstract
This meta‐analysis was performed to compare the safety, efficacy, and pharmacoeconomic of bivalirudin versus heparin in high‐risk patients for percutaneous coronary interventions (PCI). Earlier meta‐analysis comparing bivalirudin and heparin during PCI demonstrated that bivalirudin caused less bleeding with more stent thrombosis. However, little data were available on the safety of bivalirudin versus heparin in high‐risk patients for PCI. Thus, we performed a meta‐analysis to evaluate the efficacy and safety in the “high‐risk” patients. A systematic search of electronic databases was conducted up to July 30, 2020. The Cochrane Risk of Bias assessment tool was used to assess the quality of included studies. The primary outcomes were all‐cause death and major adverse cardiac events (MACE); secondary outcomes were major and minor bleeding, followed by a cost‐minimization analysis comparing bivalirudin and heparin using a local drug and medical costs reported in China. Subgroup analysis was based on the type of disease of the high‐risk population. Finally, a total of 10 randomized controlled trials involved 42,699 patients were collected. The Cochrane Risk of Bias Tool was employed to appraise the research quality. No significant difference was noted between bivalirudin and heparin regarding all‐cause death and MACE. However, subgroup analysis showed that bivalirudin caused less major bleeding in female (OR:0.65, 95% CI:0.53–0.79), diabetes (OR:0.55, 95%CI:0.42–0.73), and CKD (OR:0.59, 95%CI:0.63–1.65). The scatterers of the included literature were approximately symmetrical, and no research was outside the funnel plot. Additionally, cost‐minimization analysis showed that heparin was likely to represent a cost‐effective option compared with bivalirudin in China, with potential savings of 2129.53 Chinese Yuan (CNY) per patient for one PCI. Overall, the meta‐analysis showed that although bivalirudin appeared to have a lower risk of major bleeding rate, the overall effectiveness and safety between the two groups showed no significant difference in high‐risk patients for PCI. But the results of the cost‐minimization analysis showed that heparin could be a potential cost‐saving drug than bivalirudin in patients for PCI in China.
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Affiliation(s)
- Ke-Xin Sun
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Bin Cui
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Shan-Shan Cao
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wen-Jun Wang
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,Department of Pharmacy, Shaanxi University of Chinese Medicine, Xi'an, China
| | - Feng Yu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Jing-Wen Wang
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yi Ding
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Scandroglio AM, Pieri M, Nardelli P, Fominskiy E, Calabrò MG, Melisurgo G, Ajello S, Pappalardo F. Impact of CytoSorb on kinetics of vancomycin and bivalirudin in critically ill patients. Artif Organs 2021; 45:1097-1103. [PMID: 33686696 DOI: 10.1111/aor.13952] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/05/2021] [Accepted: 02/28/2021] [Indexed: 12/19/2022]
Abstract
CytoSorb is a promising tool to treat severe inflammatory status with multiple mechanisms in the acute care setting. Its effect on drugs is, however, poorly documented in vivo, although removal of small molecules might translate into decreased blood levels of life-saving medications. The aim of this study was to assess the impact of CytoSorb on vancomycin and bivalirudin clearance in a large population of critically ill patients. We performed a single-center analysis of CytoSorb treatments performed between January 2018 and March 2019 in critically ill patients admitted to our intensive care unit. A total of 109 CytoSorb treatments were performed in 89 patients. A decrease in lactate dehydrogenase (P = .007), troponin T (P = .022), and creatine phosphokinase (P = .013) was reported during treatment. Vancomycin dose required significant adjustments during treatment (P < .001), but no significant change was necessary after the first 3 days. Similarly, the requirements of bivalirudin significantly changed over days (P < .001), but no dose adjustment was needed after the first 3 days of treatment. No differences in terms of vancomycin and bivalirudin dose need was observed between patients on extracorporeal membrane oxygenation and those who were not (P = .6 and P = .6, respectively), between patients with and without continuous veno-venous hemofiltration (P = .9 and P = .9, respectively), and between CytoSorb responders or not (P = .4 and P = .7, respectively). CytoSorb is effective in mitigating the systemic inflammatory response and safe with respect to vancomycin and bivalirudin administration. These preliminary data further support the use of CytoSorb as adjunct therapy in critically ill patients.
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Affiliation(s)
- Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Grazia Calabrò
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Melisurgo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federico Pappalardo
- Department of Anesthesia and Intensive Care, IRCCS ISMETT, UPMC Italy, Palermo, Italy
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