Cardiovascular Events Reduction: Bivalirudin or Heparin?

The MATRIX study did not find a clear advantage of bivalirudin over unfractioned heparin to reduce major adverse cardiovascular events (MACE) or net cardiovascular adverse events (NCAE) in patients undergoing acute coronary syndrome receiving PCI.

This new analyzis confirms there is no difference in ischemic and thrombotic events in patients with acute coronary syndrome with and without ST elevation segment.

Bivalirudin has shown in other studies a benefit in mortality but only for STEMI patients.

MATRIX outcomes were originally presented at ACC 2015, and this pre-specified substudy analyzing the differences between STEMI and NSTEMI syndromes was recently published by BMJ.

Outcomes from 4,010 STEMI and 3,203 NSTEMI patients were compared. The decision to add a glycoprotein IIb/IIIa inhibitor to the heparin was left to operators’ criteria, and it reached 30.7% of STEMI and 10.9% of NSTEMI patients.

Among STEMI patients, researchers observed a 5.9% MACE rate in the bivalirudin group vs. 6.5% in the heparin group, a difference of no statistical significance.

In NSTEMI patients, MACE rate was 15.9% for bivalirudin and 16.4% for heparin, which again has no statistical difference.

For NCAE end point, which is a combination of major bleeding and MACE components (death, MI or stroke), there were no differences between bivalirudin and heparin across the whole spectrum of ACS.

There was a reduction in bleeding with bivalirudin (as prior studies have shown) but there was no excess stent thrombosis in the first hours, which differs from prior studies, probably mainly due to the fact that its protocol let extend drug infusion to full doses for four hours and a minor dose up to six hours.

Conclusion

Bivalirudin, compared to heparin and provisional glycoprotein inhibitors, did not result in a reduction of cardiovascular adverse events or net clinical adverse events in patients with or without ST elevation AMI.

Original Title: Bivalirudin or unfractionated heparin in patients with acute coronary syndromes managed invasively with and without ST elevation (MATRIX).

Reference: Leonardi S et al. BMJ. 2016; Epub ahead of print.

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