Key result
Decreasing bleeding by either a pharmacologic strategy (bivalirudin) or a technical approach (transradial access) improves survival in STEMI patients undergoing primary PCI.
Why the study?
Do bleeding reduction strategies (bivalirudin or transradial access) improve survival in STEMI patients undergoing primary PCI?
Do bleeding reduction strategies (bivalirudin or transradial access) improve survival in STEMI patients undergoing primary PCI?
Reducing bleeding complications during primary PCI for STEMI, either pharmacologically or via radial access, appears to improve overall survival.
Bleeding reduction strategies may improve survival in STEMI primary PCI; hypothesis-generating from Level 5 evidence and requires prospective RCTs before practice change.
BACKGROUND: In-hospital mortality for ST-elevation myocardial infarction (STEMI) has declined thanks to a greater use of primary percutaneous coronary interventions (PCI) associated with more effective antiplatelet and anticoagulant drugs. In this regard, bivalirudin has been shown to decrease total and cardiac mortality as compared to unfractionated heparin (UFH). OBJECTIVE: The primary purpose of this analysis is to evaluate the hypothesis that the reduction of in-hospital bleeding is the most plausible explanation for the improved survival of STEMI patients treated with bivalirudin during primary PCI. The secondary objective is to reconsider the prognostic significance of the radial access alone or in association with bivalirudin on the basis of the published data. METHODS: We have done a comprehensive evaluation of the main and related publications of the HORIZONS-AMI trial in addition to an extensive research by Medline of randomized trials evaluating the prognostic impact of radial access as compared with the femoral one in primary PCI. RESULTS: In the HORIZONS-AMI trial bivalirudin resulted in significantly lower rates of the 30 day primary endpoint (defined as major adverse ischemic outcomes plus major bleeding) over UFH plus GPI, largely due to the significantly lower rate of the protocol-defined major bleeding. All-cause and cardiac mortality were also reduced in the bivalirudin arm at 3 year follow-up. Recent studies have also shown that the use of the radial instead of the femoral approach for primary PCI is associated with reduced bleeding as well as reduced mortality. CONCLUSIONS: Our research suggests that decreasing bleeding by either a pharmacologic strategy (use of bivalirudin) or a technical approach (the transradial access) improves survival in STEMI patients undergoing primary PCI. The validity of this hypothesis should be confirmed by specific randomized trials.
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Servi et al. (2013) conducted a review in ST-elevation myocardial infarction (STEMI). Bivalirudin and/or transradial access vs. Unfractionated heparin (UFH) plus GPI and/or transfemoral access was evaluated on 30 day primary endpoint (major adverse ischemic outcomes plus major bleeding). Decreasing bleeding by either a pharmacologic strategy (bivalirudin) or a technical approach (transradial access) improves survival in STEMI patients undergoing primary PCI.
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