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Antithrombotic regimens for percutaneous coronary intervention of the left main coronary artery: The EXCEL trial

Sorin J Brener1, Nicholas J Lembo2,3, David E Kandzari4

  • 1NewYork-Presbyterian Brooklyn Methodist Hospital, New York, New York, USA.

Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions
|March 18, 2020
PubMed

Insights

Bivalirudin use during left main coronary artery percutaneous coronary intervention (PCI) increased early adverse events and bleeding compared to heparin. Five-year outcomes were similar, with no difference in stent thrombosis.

Area of Science:

  • Cardiology
  • Interventional Cardiology
  • Clinical Trials

Background:

  • Optimal antithrombotic strategy for left main coronary artery (LMCA) percutaneous coronary intervention (PCI) is debated.
  • LMCA PCI patients are underrepresented in major clinical trials.

Purpose of the Study:

  • To compare the outcomes of bivalirudin versus heparin in patients undergoing LMCA PCI.
  • To evaluate the impact of glycoprotein IIb/IIIa inhibitor (GPI) use on LMCA PCI outcomes.

Main Methods:

  • Analysis of the randomized EXCEL trial PCI cohort (n=928).
  • Comparison of bivalirudin versus heparin treatment groups.
  • Assessment of primary composite endpoint (death, MI, stroke) at 30 days and 5 years.
  • Evaluation of major bleeding and stent thrombosis rates.

Main Results:

  • Bivalirudin use was associated with higher 30-day (7.2% vs 3.8%) and 5-year (26.3% vs 19.9%) composite endpoint rates compared to heparin (p=0.02 for both).
  • Major bleeding was more frequent with bivalirudin (4.1% vs 1.3%, p=0.008).
  • No significant difference in stent thrombosis was observed between groups.

Conclusions:

  • Procedural bivalirudin use in LMCA PCI was linked to increased periprocedural myocardial infarction and 30-day adverse events without reducing bleeding.
  • Five-year outcomes were comparable between bivalirudin and heparin.
  • Glycoprotein IIb/IIIa inhibitors were infrequently used and did not impact clinical outcomes.
Abstract

Keywords:
bivalirudinglycoprotein IIb/IIIa inhibitorsheparinleft main coronary arterypercutaneous coronary intervention

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