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Heparin Versus Bivalirudin in ST-Segment Elevation Myocardial Infarction: A SCAI-Based National Survey From US
Harsh Golwala, Sadip Pant, Ambarish Pandey
1Center for Interventional Vascular Therapy, Columbia University Medical Center/New York Presbyterian Hospital, 161 Fort Washington Ave, 6th Floor, New York, NY 10032 USA. akirtane@columbia.edu.
Insights
Practices for antithrombotic therapy (ATT) in ST-segment elevation myocardial infarction (STEMI) primary percutaneous coronary intervention (PPCI) vary significantly among US cardiologists. Recent trial data have prompted some to change their ATT selection, yet more evidence is needed to unify treatment approaches.
Area of Science:
- Cardiology
- Interventional Cardiology
- Pharmacology
Background:
- Antithrombotic therapy (ATT) is recommended for ST-segment elevation myocardial infarction (STEMI) primary percutaneous coronary intervention (PPCI).
- Current practices in ATT selection for STEMI-PPCI in the US are not fully understood, especially considering recent clinical trial outcomes.
Purpose of the Study:
- To assess current US interventional cardiologist preferences for ATT selection in STEMI-PPCI.
- To understand how recent clinical trials influence ATT choices.
Main Methods:
- An electronic survey was distributed to 2676 US interventional cardiologists.
- The survey comprised 9 focused questions on ATT preferences and practices.
Main Results:
- Bivalirudin with bailout glycoprotein IIb/IIIa inhibitor (GPI) was preferred by 53% of responders.
- Significant variability was observed in ATT infusion duration and heparin dosing.
- 43% of operators reported changing their ATT practice based on recent trial results.
Conclusions:
- There is substantial variability in self-reported ATT use for STEMI-PPCI among US interventional cardiologists.
- Further data are required to inform and potentially standardize clinical practice regarding bivalirudin and unfractionated heparin in STEMI-PPCI.
Background:
The use of antithrombotic therapy (ATT) (bivalirudin or unfractionated heparin) is a class I recommendation for patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI). This survey was conducted to better understand current United States (US) practices in terms of preferences regarding the selection of ATT in STEMI-PPCI, particularly in light of recent clinical trials.
Methods:
An electronic survey consisting of 9 focused questions was forwarded to 2676 US interventional cardiologists who were members of the Society for Cardiovascular Angiography and Interventions (SCAI).
Results:
Among 390 responders (14.5%), bivalirudin with bail-out glycoprotein IIb/IIIa inhibitor (GPI) was the predominant strategy for 53% of operators, whereas 32% preferred heparin with bail-out GPI and 15% preferred heparin with more routine GPI. The duration of bivalirudin infusion varied widely among operators, and significant variability existed in the bolus dose of heparin that was preferred by operators. About 49% of respondents stated that the choice of ATT was not affected by the bleeding risk of the patient, although access site did appear to affect the choice of ATT for some operators. Notably, 43% of operators reported to have changed their practice regarding ATT in light of recent trial results.
Conclusion:
There is marked variability in self-reported ATT use in STEMI-PPCI among US interventional cardiologists. Given the patient-related variability in bleeding risk and mixed clinical trial results between the two predominant ATT agents, bivalirudin and unfractionated heparin, more data are needed in order to further inform and potentially unify clinical practice in STEMI-PPCI.