Low cardiac mortality with bivalirudin beyond the reduction in major bleeding

Original title: Reduction in Cardiac Mortality with Bivalirudin in Patients With and Without Major Bleeding: The HORIZONS-AMI Trial. Reference: Gregg W. Stone et al. J Am Coll Cardiol. Epub ahead of print

The HORIZONS -AMI study included 3602 patients experiencing ST  segment elevation myocardial infarction received primary angioplasty, resulting in lower mortality at 30 days and three years in those receiving  anticoagulation with bivalirudin (a direct inhibitor of thrombin) versus those who received heparin plus glycoprotein inhibitors .

The mechanism to explain this difference in mortality could be attributed to the reduction in the rate of major bleeding , however there may be other mechanisms. Treatment with bivalirudin resulted in lower mortality from all causes ( 5.9 % vesus 7.7 % , HR 0.75 , 95% CI 0.58 to 0.97 , P = 0.03 ) and lower cardiac mortality ( 2.9 % versus 5.1 % , HR = 0.56 , 95% CI 0.40 to 0.80 , P = 0.001 ) with a similar noncardiac mortality beyond the bleeding .Bivalirudin bleeding was also less at 3 years ( 6.9 % vrsus 10.5 % , HR = 0.64 , 95% CI 0.51 to 0.80 , P = 0.0001 ) and less reinfarction, unlike stroke rates , stent thrombosis, and revascularization which were similar between the two branches. Patients with major bleeding , as expected , showed increased mortality at 3 years compared with those who did not bleed . However, it is noteworthy that when evaluating only patients who bled , those who received bivalirudin had lower mortality than those who bled more with heparin plus IIbIIIa. Minor bleeding was not associated with mortality , whatever the treatment branch. Acquired thrombocytopenia was strongly associated with cardiac mortality and was significantly more frequent with heparin plus glycoprotein inhibitors.

Conclusion: 

Bivalirudin reduces cardiac mortality in patients experiencing  ST  segment elevation myocardial infarction received primary angioplasty.

Editorial Comment:

This effect on mortality can be only partially explained by the reduction in bleeding,  so more studies are needed to identify the benefit of bivalirudin non hematologic . Possible explanations are the reduction in inflammation and apoptosis besides improving post- ischemic cardiac function by blocking PAR-1 , and PAR -4 receptors.

SOLACI.ORG

More articles by this author

Coronary Artery Disease in Aortic Stenosis: CABG + SAVR vs. TAVR + PCI: Data from Spanish Centers

Multiple randomized studies have shown comparable or superior efficacy of transcatheter aortic valve replacement (TAVR) vs. coronary artery bypass graft (CABG).  However, many of...

Evolution of Small Balloon-Expandable Valves

Small aortic rings (20 mm) have posed a significant challenge for both surgery and transcatheter aortic valve implantation (TAVI) due to their association with an...

TCT 2024 | FAVOR III EUROPA

The study FAVOR III EUROPA, a randomized trial, included 2,000 patients with chronic coronary syndrome, or stabilized acute coronary syndrome, and intermediate lesions. 1,008...

TCT 2024 – ECLIPSE: Randomized Study of Orbital Atherectomy vs Conventional PCI in Severely Calcified Lesions

Coronary calcification is associated with stent under-expansion and increased risk of both early and late adverse events. Atherectomy is an essential tool for uncrossable...

LEAVE A REPLY

Please enter your comment!
Please enter your name here

Related Articles

SOLACI Sessionsspot_img

Recent Articles

Severe Tricuspid Regurgitation: Surgical vs. Transcatheter Edge-to-Edge Repair

While highly prevalent, tricuspid regurgitation is a notably undertreated valvulopathy. Its progression has been associated with higher mortality and significant disability. According to the...

ACCESS-TAVI: Comparing Post TAVR Vascular Closure Devices

Transcatheter aortic valve replacement (TAVR) is a well-established option to treat elderly patients with severe symptomatic aortic valve stenosis. Technical advances and device development...

Endovascular Treatment of Iliofemoral Disease for the Improvement of Heart Failure with Preserved Ejection Fraction

Peripheral artery disease (PAD) is a significant risk factor in the development of difficult-to-treat conditions, such as heart failure with preserved ejection fraction (HFpEF)....