Heparin vs Bivalirudin in STEMI

Abstract and Introduction

Abstract

Background. The use of antithrombotic therapy (ATT) (bivalirudin or unfractionated heparin) is a class I recommendation for patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI). This survey was conducted to better understand current United States (US) practices in terms of preferences regarding the selection of ATT in STEMI-PPCI, particularly in light of recent clinical trials.

Methods. An electronic survey consisting of 9 focused questions was forwarded to 2676 US interventional cardiologists who were members of the Society for Cardiovascular Angiography and Interventions (SCAI).

Results. Among 390 responders (14.5%), bivalirudin with bail-out glycoprotein IIb/IIIa inhibitor (GPI) was the predominant strategy for 53% of operators, whereas 32% preferred heparin with bail-out GPI and 15% preferred heparin with more routine GPI. The duration of bivalirudin infusion varied widely among operators, and significant variability existed in the bolus dose of heparin that was preferred by operators. About 49% of respondents stated that the choice of ATT was not affected by the bleeding risk of the patient, although access site did appear to affect the choice of ATT for some operators. Notably, 43% of operators reported to have changed their practice regarding ATT in light of recent trial results.

Conclusion. There is marked variability in self-reported ATT use in STEMI-PPCI among US interventional cardiologists. Given the patient-related variability in bleeding risk and mixed clinical trial results between the two predominant ATT agents, bivalirudin and unfractionated heparin, more data are needed in order to further inform and potentially unify clinical practice in STEMI-PPCI.

Introduction

The use of antithrombotic agents (ATTs) – typically either bivalirudin or unfractionated heparin – carries a class I recommendation in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI).^[1] The recent HEAT-PPCI, EUROMAX, BRIGHT, NAPLES-III, and MATRIX trials, as well as meta-analyses, have provided mixed results in terms of the optimal choice of ATT in STEMI patients undergoing PPCI.^[2–12] While the majority of trials have demonstrated bleeding reductions with a bivalirudin-based strategy compared with heparin (especially when heparin is used in conjunction with adjunctive glycoprotein IIb/IIIa inhibitor [GPI]), an increase in acute stent thrombosis has also been observed consistently with bivalirudin monotherapy in the STEMI setting, particularly when bivalirudin is stopped at the end of the PCI.^[5]

Given the variability in the clinical trial data as well as polarized responses to these recent data that have been observed,^[13] we hypothesized that there would be significant variations in the choice, dosing, and other factors influencing the selection of ATT for STEMI-PPCI among United States (US) interventional cardiologists.

Table 1. Survey questions and answer choices with response counts and percentages.
	Response Rate/Responders
1. Approximately how many STEMI interventions do you perform in 1 year?
<10	12/391 (3.1%)
10–25	161/391 (41.2%)
26–50	156/391 (39.9%)
>50	62/391 (15.9%)
2. What is the dominant choice of antithrombotic therapy in your lab for STEMI?
Heparin monotherapy with bail-out GPI	124/390 (31.8%)
Bivalirudin monotherapy with bail-out GPI	208/390 (53.3%)
Heparin + GPI (GPI in majority of cases)	58/390 (14.9%)
3. If you are using heparin for STEMI-PCI (not CTO-PCI), which of the following regimens do you think is most appropriate?
Heparin <70 U/kg, with subsequent boluses based on ACT	51/330 (15.5%)
Heparin 70 U/kg, with subsequent boluses based on ACT	191/330 (57.9%)
Heparin >70 but <100 U/kg, with subsequent boluses based on ACT	59/330 (17.9%)
Heparin 100 U/kg, with subsequent boluses based on ACT	29/330 (8.8%)
Heparin >100 U/kg, with subsequent boluses based on ACT	0/330 (0.0%)
4. What is the dose of bivalirudin preferred during STEMI-PCI?
Bivalirudin 0.75 mg/kg bolus followed by 1.75 mg/kg/hr stopped at the end of the procedure	137/383 (35.8%)
Bivalirudin 0.75 mg/kg bolus followed by 1.75 mg/kg/hr infusion until the completion of the bag	131/383 (34.2%)
Bivalirudin 0.75 mg/kg bolus followed by 1.75 mg/kg/hr infusion for 30 min after the completion of the procedure	34/383 (8.9%)
Bivalirudin 0.75 mg/kg bolus followed by 1.75 mg/kg/hr infusion for 2 hrs after the completion of the procedure	81/383 (21.2%)
5. Does patient bleeding risk influence your choice of antithrombotic agent?
Patient's bleeding risk does not affect my choice of antithrombotic agent	191/390 (49.0%)
For high bleeding risk, I use bivalirudin	164/390 (42.1%)
For high bleeding risk, I use heparin	35/390 (9.0%)
6. Does access site influence your choice of antithrombotic agent?
For radial access, I favor bivalirudin; for femoral access, I favor heparin	3/389 (0.8%)
For radial access, I favor heparin; for femoral access, I favor bivalirudin	59/389 (15.2%)
I use heparin for both radial and femoral access	141/389 (36.3%)
I use bivalirudin for both radial and femoral access	186/389 (47.8%)
7. Does the cost of antithrombotic agent influence the choice of antithrombotic agent utilized by you in your lab?
Yes	153/391 (39.1%)
No	238/391 (60.9%)
8. Have recent trial data from EUROMAX, HEAT-PPCI, BRIGHT, and recent meta-analyses influenced your choice of
anticoagulants during PCIs for ACS?
Yes – I am using more heparin	159/389 (40.9%)
Yes – I am using more bivalirudin	7/389 (1.8%)
No – I have continued to do what I was doing before	223/389 (57.3%)
9. What is your primary catheterization laboratory setting?
Private hospital	190/392 (48.5%)
Semi-academic	74/392 (18.9%)
Academic	128/392 (32.7%)

Table 1. Survey questions and answer choices with response counts and percentages.

Response Rate/Responders

1. Approximately how many STEMI interventions do you perform in 1 year?

<10

12/391 (3.1%)

10–25

161/391 (41.2%)

26–50

156/391 (39.9%)

>50

62/391 (15.9%)

2. What is the dominant choice of antithrombotic therapy in your lab for STEMI?

Heparin monotherapy with bail-out GPI

124/390 (31.8%)

Bivalirudin monotherapy with bail-out GPI

208/390 (53.3%)

Heparin + GPI (GPI in majority of cases)

58/390 (14.9%)

3. If you are using heparin for STEMI-PCI (not CTO-PCI), which of the following regimens do you think is most appropriate?

Heparin <70 U/kg, with subsequent boluses based on ACT

51/330 (15.5%)

Heparin 70 U/kg, with subsequent boluses based on ACT

191/330 (57.9%)

Heparin >70 but <100 U/kg, with subsequent boluses based on ACT

59/330 (17.9%)

Heparin 100 U/kg, with subsequent boluses based on ACT

29/330 (8.8%)

Heparin >100 U/kg, with subsequent boluses based on ACT

0/330 (0.0%)

4. What is the dose of bivalirudin preferred during STEMI-PCI?

Bivalirudin 0.75 mg/kg bolus followed by 1.75 mg/kg/hr stopped at the end of the procedure

137/383 (35.8%)

Bivalirudin 0.75 mg/kg bolus followed by 1.75 mg/kg/hr infusion until the completion of the bag

131/383 (34.2%)

Bivalirudin 0.75 mg/kg bolus followed by 1.75 mg/kg/hr infusion for 30 min after the completion of the procedure

34/383 (8.9%)

Bivalirudin 0.75 mg/kg bolus followed by 1.75 mg/kg/hr infusion for 2 hrs after the completion of the procedure

81/383 (21.2%)

5. Does patient bleeding risk influence your choice of antithrombotic agent?

Patient's bleeding risk does not affect my choice of antithrombotic agent

191/390 (49.0%)

For high bleeding risk, I use bivalirudin

164/390 (42.1%)

For high bleeding risk, I use heparin

35/390 (9.0%)

6. Does access site influence your choice of antithrombotic agent?

For radial access, I favor bivalirudin; for femoral access, I favor heparin

3/389 (0.8%)

For radial access, I favor heparin; for femoral access, I favor bivalirudin

59/389 (15.2%)

I use heparin for both radial and femoral access

141/389 (36.3%)

I use bivalirudin for both radial and femoral access

186/389 (47.8%)

7. Does the cost of antithrombotic agent influence the choice of antithrombotic agent utilized by you in your lab?

Yes

153/391 (39.1%)

238/391 (60.9%)

8. Have recent trial data from EUROMAX, HEAT-PPCI, BRIGHT, and recent meta-analyses influenced your choice of

anticoagulants during PCIs for ACS?

Yes – I am using more heparin

159/389 (40.9%)

Yes – I am using more bivalirudin

7/389 (1.8%)

No – I have continued to do what I was doing before

223/389 (57.3%)

9. What is your primary catheterization laboratory setting?

Private hospital

190/392 (48.5%)

Semi-academic

74/392 (18.9%)

Academic

128/392 (32.7%)

Annual Operator Volume	Heparin Monotherapy With Bail-out GPI	Bivalirudin Monotherapy With Bail-out GPI	Heparin + GPI (GPI in Majority of Cases)
<10	25%	67%	0%
10–25	29%	53%	17%
25–50	34%	55%	11%
>50	34%	47%	19%

Heparin Versus Bivalirudin in ST-segment Elevation Myocardial Infarction

A SCAI-Based National Survey From US Interventional Cardiologists

Abstract and Introduction

Abstract

Introduction

Heparin Versus Bivalirudin in ST-segment Elevation Myocardial Infarction

A SCAI-Based National Survey From US Interventional Cardiologists

Abstract and Introduction

Abstract

Introduction

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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