Journal of Thrombosis and Thrombolysis

, Volume 31, Issue 4, pp 401–406 | Cite as

Two hour bivalirudin infusion after PCI for ST elevation myocardial infarction

  • Phillip R. Anderson
  • Prospero B. Gogo
  • Bina Ahmed
  • Faye Straight
  • Edward F. Terrien
  • Matthew W. Watkins
  • Nader El Gharib
  • Harold L. Dauerman
Article

Abstract

The standard of care for STEMI PCI for the past decade has been aspirin, clopidogrel, heparin, and a glycoprotein IIbIIIa receptor inhibitor (GPI). A bivalirudin strategy was shown to be superior to a GPI strategy in the HORIZONS AMI trial for net adverse clinical events (combined MACE and bleeding). An increased risk of acute stent thrombosis in the bivalirudin arm may have prevented broader adoption of bivalirudin for this indication. We hypothesized that acute stent thrombosis risk could be ameliorated by a 2 h infusion of bivalirudin following STEMI PCI. We implemented a multicenter, prospective registry for all STEMI patients in Vermont treated at a single PCI center. Each patient was routinely pre-loaded with dual antiplatelet therapy and 75% received an unfractionated heparin bolus prior to PCI. The utilization of bivalirudin bolus and continued 2 h infusion after PCI was routine with GPI bailout optional. 128 consecutive STEMI patients underwent primary PCI from October 1, 2008 to September 30, 2009. 92% of primary PCI patients received bivalrudin during and after the procedure with a 9% rate of bail out GPI. There was one case of probable or definite acute stent thrombosis (0.7%), and this single case occurred despite use of bailout GPI. Despite the prolonged infusion of bivalirudin, major bleeding occurred in only 1.7% of STEMI patients. In conclusion, prolonging bivalirudin for 2 h after STEMI PCI may be a promising method to alleviate acute stent thrombosis risk without losing the bleeding complication benefit of the bivalirudin strategy.

Keywords

Bivalrudin STEMI Stent thrombosis 

References

  1. 1.
    Dauerman HL, Frederick PD, Miller D, French WJ (2007) Current incidence and clinical outcomes of bivalirudin administration among patients undergoing primary coronary intervention for stent thrombosis elevation acute myocardial infarction. Coron Artery Dis 18(2):141–148PubMedCrossRefGoogle Scholar
  2. 2.
    Mehran R, Lansky AJ, Witzenbichler B, Guagliumi G, Peruga JZ, Brodie BR, Dudek D, Kornowski R, Hartmann F, Gersh BJ, Pocock SJ, Wong SC, Nikolsky E, Gambone L, Vandertie L, Parise H, Dangas GD, Stone GW (2009) Bivalirudin in patients undergoing primary angioplasty for acute myocardial infarction (horizons-ami): 1-year results of a randomised controlled trial. Lancet 374(9696):1149–1159PubMedCrossRefGoogle Scholar
  3. 3.
    Stone GW, Witzenbichler B, Guagliumi G, Peruga JZ, Brodie BR, Dudek D, Kornowski R, Hartmann F, Gersh BJ, Pocock SJ, Dangas G, Wong SC, Kirtane AJ, Parise H, Mehran R (2008) Bivalirudin during primary pci in acute myocardial infarction. N Engl J Med 358(21):2218–2230PubMedCrossRefGoogle Scholar
  4. 4.
    Hochholzer W, Trenk D, Frundi D, Blanke P, Fischer B, Andris K, Bestehorn HP, Buttner HJ, Neumann FJ (2005) Time dependence of platelet inhibition after a 600-mg loading dose of clopidogrel in a large, unselected cohort of candidates for percutaneous coronary intervention. Circulation 111(20):2560–2564PubMedCrossRefGoogle Scholar
  5. 5.
    Ahmed B, Lischke S, Straight F, Gogo P, Leffler S, Kutler M, Schneider DJ, Dauerman HL (2009) Consistent door-to-balloon times of less than 90 min for stemi patients transferred for primary pci. J Invasive Cardiol 21(9):429–433PubMedGoogle Scholar
  6. 6.
    Mehran R, Brodie B, Cox DA, Grines CL, Rutherford B, Bhatt DL, Dangas G, Feit F, Ohman EM, Parise H, Fahy M, Lansky AJ, Stone GW (2008) The harmonizing outcomes with revascularization and stents in acute myocardial infarction (horizons-ami) trial: study design and rationale. Am Heart J 156(1):44–56PubMedCrossRefGoogle Scholar
  7. 7.
    Ahmed B, Piper WD, Malenka D, VerLee P, Robb J, Ryan T, Herne M, Phillips W, Dauerman HL (2009) Significantly improved vascular complications among women undergoing percutaneous coronary intervention: a report from the northern new england percutaneous coronary intervention registry. Circ Cardiovasc Interv 2(5):423–429PubMedCrossRefGoogle Scholar
  8. 8.
    Cutlip DE, Windecker S, Mehran R, Boam A, Cohen DJ, van Es GA, Steg PG, Morel MA, Mauri L, Vranckx P, McFadden E, Lansky A, Hamon M, Krucoff MW, Serruys PW (2007) Clinical end points in coronary stent trials: a case for standardized definitions. Circulation 115(17):2344–2351PubMedCrossRefGoogle Scholar
  9. 9.
    Peterson ED, Dai D, DeLong ER, Brennan JM, Singh M, Rao SV, Shaw RE, Roe MT, Ho KK, Klein LW, Krone RJ, Weintraub WS, Brindis RG, Rumsfeld JS, Spertus JA (2010) Contemporary mortality risk prediction for percutaneous coronary intervention: results from 588, 398 procedures in the national cardiovascular data registry. J Am Coll Cardiol 55(18):1923–1932PubMedCrossRefGoogle Scholar
  10. 10.
    Elbarouni B, Goodman SG, Yan RT, Welsh RC, Kornder JM, Deyoung JP, Wong GC, Rose B, Grondin FR, Gallo R, Tan M, Casanova A, Eagle KA, Yan AT (2009) Validation of the global registry of acute coronary event (grace) risk score for in-hospital mortality in patients with acute coronary syndrome in canada. Am Heart J 158(3):392–399PubMedCrossRefGoogle Scholar
  11. 11.
    Dauerman HL, Lessard D, Yarzebski J, Gore JM, Goldberg RJ (2005) Bleeding complications in patients with anemia and acute myocardial infarction. Am J Cardiol 96(10):1379–1383PubMedCrossRefGoogle Scholar
  12. 12.
    Kereiakes DJ, Choo JK, Young JJ, Broderick TM (2004) Thrombosis and drug-eluting stents: a critical appraisal. Rev Cardiovasc Med 5(1):9–15PubMedCrossRefGoogle Scholar
  13. 13.
    Dangas G, Mehran R, Guagliumi G, Caixeta A, Witzenbichler B, Aoki J, Peruga JZ, Brodie BR, Dudek D, Kornowski R, Rabbani LE, Parise H, Stone GW (2009) Role of clopidogrel loading dose in patients with st-segment elevation myocardial infarction undergoing primary angioplasty: results from the horizons-ami (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trial. J Am Coll Cardiol 54(15):1438–1446PubMedCrossRefGoogle Scholar
  14. 14.
    Antman EM, Wiviott SD, Murphy SA, Voitk J, Hasin Y, Widimsky P, Chandna H, Macias W, McCabe CH, Braunwald E (2008) Early and late benefits of prasugrel in patients with acute coronary syndromes undergoing percutaneous coronary intervention: a triton-timi 38 (trial to assess improvement in therapeutic outcomes by optimizing platelet inhibition with prasugrel-thrombolysis in myocardial infarction) analysis. J Am Coll Cardiol 51(21):2028–2033PubMedCrossRefGoogle Scholar
  15. 15.
    Stone GW, Ware JH, Bertrand ME, Lincoff AM, Moses JW, Ohman EM, White HD, Feit F, Colombo A, McLaurin BT, Cox DA, Manoukian SV, Fahy M, Clayton TC, Mehran R, Pocock SJ (2007) Antithrombotic strategies in patients with acute coronary syndromes undergoing early invasive management: one-year results from the acuity trial. JAMA 298(21):2497–2506PubMedCrossRefGoogle Scholar
  16. 16.
    Feit F, Voeltz MD, Attubato MJ, Lincoff AM, Chew DP, Bittl JA, Topol EJ, Manoukian SV (2007) Predictors and impact of major hemorrhage on mortality following percutaneous coronary intervention from the replace-2 trial. Am J Cardiol 100(9):1364–1369PubMedCrossRefGoogle Scholar
  17. 17.
    Bittl JA, Strony J, Brinker JA, Ahmed WH, Meckel CR, Chaitman BR, Maraganore J, Deutsch E, Adelman B (1995) Treatment with bivalirudin (hirulog) as compared with heparin during coronary angioplasty for unstable or postinfarction angina. Hirulog angioplasty study investigators. N Engl J Med 333(12): 764–769PubMedCrossRefGoogle Scholar
  18. 18.
    Piper WD, Malenka DJ, Ryan TJ Jr, Shubrooks SJ Jr, O’Connor GT, Robb JF, Farrell KL, Corliss MS, Hearne MJ, Kellett MA Jr, Watkins MW, Bradley WA, Hettleman BD, Silver TM, McGrath PD, O’Mears JR, Wennberg DE (2003) Predicting vascular complications in percutaneous coronary interventions. Am Heart J 145(6):1022–1029PubMedCrossRefGoogle Scholar
  19. 19.
    Sanborn TA, Ebrahimi R, Manoukian SV, McLaurin BT, Cox DA, Feit F, Hamon M, Mehran R, Stone GW (2010) Impact of femoral vascular closure devices and antithrombotic therapy on access site bleeding in acute coronary syndromes: the acute catheterization and urgent intervention triage strategy (acuity) trial. Circ Cardiovasc Interv 3(1):57–62PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Phillip R. Anderson
    • 1
  • Prospero B. Gogo
    • 1
  • Bina Ahmed
    • 1
  • Faye Straight
    • 1
  • Edward F. Terrien
    • 1
  • Matthew W. Watkins
    • 1
  • Nader El Gharib
    • 1
  • Harold L. Dauerman
    • 1
  1. 1.McClure 1 CardiologyFletcher Allen Health CareBurlingtonUSA

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