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N Engl J Med. 2013 Dec 5;369(23):2207-17. doi: 10.1056/NEJMoa1311096. Epub 2013 Oct 30.

Bivalirudin started during emergency transport for primary PCI.

Collaborators (168)

Steg PG, Adgey J, Clemmensen P, Goldstein P, Hamon M, van 't Hof A, Nibbe L, Zeymer U, Hamm CW, Hill J, Quinn T, Clemmensen P, Steinmetz J, Coste P, Lapostolle F, Cavallini C, Gordini G, Verheugt FW, ten Berg J, Zeymer U, Nibbe L, Hirschl M, Huber K, Cequier A, Dudek D, Widimský P, Kanic V, Danchin N, Ford I, Maggioni A, Mehran R, Montalescot G, Mehta CR, Clayton TC, Pocock SJ, Thygesen K, Bagger J, Huber K, Winkler M, Malzer R, Toušek F, Gutvirth J, Clemmensen P, Steinmetz J, Hansen PR, Hestad S, Kristensen SD, Juelsgaard P, Thayssen P, Mikkelsen S, Steg PG, Vassor I, Coste P, Thicoipe M, Lecoq G, Bonnieux D, Dib JC, Delarche N, Pouyanne-Dandonneau I, Auffray JL, Goldstein P, Bouvaist H, Debaty G, Faurie B, Hammer L, Lefèvre T, Briole N, Ta T, Lafont A, Cahun-Giraud S, Goube P, Tazarourte K, Teiger E, Marty J, Carrie D, Ducasse JL, Fajadet J, Benamer H, Cattan S, Lapostolle F, Guibert A, Chapon P, Echahed K, Robin C, Canu G, Rihani R, Tabone X, Saudeau L, Soulat L, El Khoury C, Brunelle F, Motreff, Dissait F, Rosey G, Dubreuil O, Georges JL, Lambert Y, Nef H, Campo dell' Orto M, Zeymer U, Mark B, Möckel M, Nibbe L, Fichtlscherer S, Ehrlich J, Bufe A, Koerner-Goebel H, Fischer D, Reiffen HP, Wessely R, Marx F, Weiss C, Frenkel C, Tessin S, Mochmann H, Hambrecht R, Tonner P, Marzocchi A, Gordini G, Di Pasquale G, Cavallini C, Borgognoni F, Angelucci M, Uguccioni L, Grini M, Marchetti B, ten Berg JM, van Grunsven P, Lichtveld RA, Heutz W, van 't Hof A, Eggink G, Oetomo S, Sandjer T, Brouwer M, van Grunsven P, Voskuil M, Hamer B, Ophuis TO, Dudek D, Mirek-Bryniarska E, Peruga JZ, Kogucki J, Rosciszewska-Kuncman A, Wlazlowski R, Buszman P, Hamankiewicz M, Maliszewski M, Janik A, Szymkiewicz G, Wójcik J, Kocon S, Rączka M, Mlodziankowski A, Zietek Z, Nowak R, Bieniasz J, Dragan J, Kukla P, Żurakowski A, Palka M, Macek J, Wojdyla R, Wrzak L, Gucwa J, Kanic V, Macek R, Mally S.

Author information

1
The authors' affiliations are listed in the Appendix.

Abstract

BACKGROUND:

Bivalirudin, as compared with heparin and glycoprotein IIb/IIIa inhibitors, has been shown to reduce rates of bleeding and death in patients undergoing primary percutaneous coronary intervention (PCI). Whether these benefits persist in contemporary practice characterized by prehospital initiation of treatment, optional use of glycoprotein IIb/IIIa inhibitors and novel P2Y12 inhibitors, and radial-artery PCI access use is unknown.

METHODS:

We randomly assigned 2218 patients with ST-segment elevation myocardial infarction (STEMI) who were being transported for primary PCI to receive either bivalirudin or unfractionated or low-molecular-weight heparin with optional glycoprotein IIb/IIIa inhibitors (control group). The primary outcome at 30 days was a composite of death or major bleeding not associated with coronary-artery bypass grafting (CABG), and the principal secondary outcome was a composite of death, reinfarction, or non-CABG major bleeding.

RESULTS:

Bivalirudin, as compared with the control intervention, reduced the risk of the primary outcome (5.1% vs. 8.5%; relative risk, 0.60; 95% confidence interval [CI], 0.43 to 0.82; P=0.001) and the principal secondary outcome (6.6% vs. 9.2%; relative risk, 0.72; 95% CI, 0.54 to 0.96; P=0.02). Bivalirudin also reduced the risk of major bleeding (2.6% vs. 6.0%; relative risk, 0.43; 95% CI, 0.28 to 0.66; P<0.001). The risk of acute stent thrombosis was higher with bivalirudin (1.1% vs. 0.2%; relative risk, 6.11; 95% CI, 1.37 to 27.24; P=0.007). There was no significant difference in rates of death (2.9% vs. 3.1%) or reinfarction (1.7% vs. 0.9%). Results were consistent across subgroups of patients.

CONCLUSIONS:

Bivalirudin, started during transport for primary PCI, improved 30-day clinical outcomes with a reduction in major bleeding but with an increase in acute stent thrombosis. (Funded by the Medicines Company; EUROMAX ClinicalTrials.gov number, NCT01087723.).

PMID:
24171490
DOI:
10.1056/NEJMoa1311096
[Indexed for MEDLINE]
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