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Published on: May 28, 2019
Safety of eptifibatide when added to bivalirudin during ST-segment elevation myocardial infarction
Nevin C Baker1, Ricardo O Escarcega1, Marco A Magalhaes1
1Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
Insights
Adding eptifibatide to bivalirudin for ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) did not increase major bleeding. Outcomes were similar, suggesting combination therapy is a viable option for high-risk STEMI patients when needed.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Pharmacology
Background:
- ST-segment elevation myocardial infarction (STEMI) patients face high risks of adverse events and bleeding during hospitalization.
- The safety and efficacy of combining eptifibatide with bivalirudin in STEMI patients undergoing primary percutaneous coronary intervention (PCI) remain underexplored.
Purpose of the Study:
- To evaluate the safety and in-hospital outcomes of using eptifibatide in addition to bivalirudin in STEMI patients undergoing primary PCI.
- To compare the incidence of major bleeding and key efficacy endpoints between bivalirudin monotherapy and combination therapy.
Main Methods:
- A retrospective analysis of 1849 STEMI patients undergoing primary PCI over 11 years.
- Comparison between 1639 patients receiving bivalirudin monotherapy and 210 patients receiving bivalirudin plus eptifibatide.
- Safety assessed by Thrombolysis in Myocardial Infarction (TIMI) major bleeding; efficacy by in-hospital death, Q-wave MI, and acute stent thrombosis, with multivariate analysis for adjustment.
Main Results:
- The combination therapy group showed higher rates of cardiogenic shock, aspiration thrombectomy, and pre-PCI flow ≤1, indicating a higher-risk patient profile.
- Despite these baseline differences, the primary endpoint (death, Q-wave MI, or stent thrombosis) was not significantly different between groups after adjustment (OR: 1.63; 95% CI, 0.90-2.96).
- Crucially, Thrombolysis in Myocardial Infarction (TIMI) major bleeding rates were similar between the bivalirudin monotherapy and combination therapy groups (OR 1.78; 95% CI, 0.79-2.95).
Conclusions:
- The addition of eptifibatide to bivalirudin in primary PCI for STEMI patients identifies a high-risk cohort.
- This combination therapy achieves similar in-hospital outcomes without a significant increase in major bleeding.
- Combination therapy may be considered for high-risk STEMI patients undergoing primary PCI when clinically indicated.
Background:
Patients presenting with ST-segment elevation myocardial infarction (STEMI) represent a high-risk group for in-hospital adverse events and bleeding. The safety and outcomes of eptifibatide in addition to bivalirudin in this population have not been determined.
Methods:
Over an 11-year period, we identified 1849 STEMI patients undergoing primary percutaneous coronary intervention (PCI), of which 1639 received bivalirudin monotherapy compared with 210 patients who received both bivalirudin and provisional eptifibatide. Safety of combination therapy was assessed by the occurrence of thrombolysis in myocardial infarction (TIMI) major bleeding. In-hospital event rates of death, Q-wave myocardial infarction (MI), and acute stent thrombosis were evaluated for efficacy. Multivariate analysis was used to adjust for significant differences between groups.
Results:
Patients treated with bivalirudin plus eptifibatide, when compared with patients with bivalirudin monotherapy, had increased rates of cardiogenic shock (15.7% vs. 9.4%), aspiration thrombectomy (48.5% vs. 23.7%), pre-TIMI flow ≤1 (63.5% vs. 40%), and higher peak troponin I (93.65±92.7 vs. 49.16±81.59; all p <0.01). These, however, were not associated with differences in the primary end point after adjusting for significant baseline and procedural characteristics (OR: 1.63; 95% CI, 0.90-2.96, p=0.12). Importantly, TIMI major bleeding was not significantly different between groups (OR 1.78; 95% CI, 0.79-2.95, p=0.20).
Conclusion:
The addition of eptifibatide to bivalirudin during primary PCI reflects a high-risk STEMI population. This therapy results in similar in-hospital outcomes without an increase in major bleeding. Therefore, when required, combination therapy may be considered in this population.
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