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What is the optimal antithrombotic strategy in primary percutaneous coronary intervention?
Ziad Sergie1, Roxana Mehran, Gregg W Stone
1Mount Sinai School of Medicine, New York, New York 10029, USA.
Insights
The updated Bleeding Academic Research Consortium (BARC) definition standardizes bleeding event measurement. Bivalirudin, an antithrombin agent, reduces bleeding complications and mortality in acute coronary syndromes, becoming a preferred treatment.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Major bleeding is a significant risk factor for adverse cardiac events and mortality in acute coronary syndromes (ACS) and percutaneous coronary intervention (PCI).
- Antithrombotic agents have differential effects on ischemic and bleeding complications.
Purpose of the Study:
- To review the updated Bleeding Academic Research Consortium (BARC) definition for consistent bleeding event measurement.
- To evaluate the role of bivalirudin in managing ACS, focusing on bleeding complications and mortality.
Main Methods:
- Review of recent studies on antithrombotic agents in ACS and PCI.
- Analysis of the Bleeding Academic Research Consortium (BARC) updated definition for bleeding events.
- Evaluation of bivalirudin's efficacy and safety compared to heparin plus glycoprotein IIb/IIIa inhibitors.
Main Results:
- The BARC definition provides a standardized approach to measuring bleeding events.
- Bivalirudin demonstrated fewer bleeding complications, including in-hospital, access-site, and non-access site bleeding.
- Bivalirudin showed lower long-term mortality with similar efficacy compared to heparin plus glycoprotein IIb/IIIa inhibitors, even with preprocedural heparin use.
Conclusions:
- The BARC definition is an advancement in bleeding classification, crucial for future clinical trials and analyses.
- Bivalirudin effectively reduces bleeding events across various settings and definitions.
- Bivalirudin is now the preferred antithrombotic agent for managing acute coronary syndromes due to its safety and efficacy profile.
Purpose Of Review:
Major bleeding in the setting of acute coronary syndromes and percutaneous coronary intervention has been associated with increased short-term and long-term risk for adverse cardiac events and mortality. Recent studies on antithrombotic agents in this setting have highlighted their differential impact on ischemic and hemorrhagic complications.
Recent Findings:
To measure bleeding events consistently, an updated standardized definition has been developed by the Bleeding Academic Research Consortium (BARC) representatives. Additionally, the antithrombin agent bivalirudin has emerged as a frontrunner in the invasive management of acute coronary syndromes because of fewer bleeding complications, lower long-term mortality, and similar efficacy compared with heparin plus a glycoprotein IIb/IIIa inhibitor. The mortality benefit with bivalirudin is most likely correlated with reductions in major bleeding, including in-hospital, access-site, and nonaccess site bleeding, and despite the use of preprocedural unfractionated heparin.
Summary:
The BARC definition is an improved version of prior bleeding classifications, and will likely play a significant role in comparing different anticoagulation strategies in future clinical trials and registry analyses. Bivalirudin has been shown to reduce bleeding events in a multitude of diverse clinical settings and bleeding definitions, and has become the preferred antithrombotic agent in the setting of acute coronary syndromes.
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