PMID- 23442811
OWN - NLM
STAT- MEDLINE
DCOM- 20140212
LR  - 20161125
IS  - 1558-2035 (Electronic)
IS  - 1558-2027 (Linking)
VI  - 14
IP  - 5
DP  - 2013 May
TI  - The bivalirudin paradox: high evidence, low use.
PG  - 334-41
LID - 10.2459/JCM.0b013e32835f1915 [doi]
AB  - A series of trials have shown that bivalirudin, a direct thrombin inhibitor that 
      does not require the cofactor antithrombin III to be effective, is a reasonable 
      alternative to unfractionated heparin (UFH) alone or associated with glycoprotein 
      IIb/IIIa antagonists (GPI) in patients undergoing percutaneous coronary 
      interventions (PCI). Particularly in patients with acute coronary syndromes 
      (ACS), the effects of bivalirudin are striking. In the HORIZONS-AMI trial, 
      patients with persistent ST-segment elevation (STEMI) had lower 30-day rates of 
      net adverse clinical events and major bleeding, largely due to the significantly 
      lower 30-day rate of non-coronary artery bypass grafting major bleeding. 
      Bivalirudin also resulted in significantly lower rates of all-cause mortality and 
      cardiac mortality, a benefit that extended up to 3-year follow-up. The beneficial 
      effects of bivalirudin as compared to UFH associated with abciximab were also 
      observed in 1721 non-ST elevation myocardial infarction (NSTEMI) patients 
      undergoing PCI in the ISAR REACT 4 study. Although no difference was found 
      between the two treatment strategies in the 30-day primary endpoint, bivalirudin 
      use resulted in a lower rate of major bleeding. Despite the abundant evidence of 
      benefit provided by bivalirudin in the treatment of ACS and the high level of 
      recommendation received by the most recent Guidelines, its use is still low. The 
      reasons for this underuse are multifactorial, the most likely being the 
      preference of operators for the use of a low-cost agent, like UFH, that can be 
      associated with a GPI. Countering platelet hyperreactivity is still the main goal 
      of interventional cardiologists treating ACS patients invasively, apparently 
      downplaying the pathogenetic role of thrombin in this clinical condition.
FAU - De Servi, Stefano
AU  - De Servi S
AD  - Cardiovascular Department, AO Ospedale Civile, Legnano, Italy. 
      stefano.deservi@ao-legnano.it
FAU - Mariani, Giuseppe
AU  - Mariani G
FAU - Mariani, Matteo
AU  - Mariani M
FAU - D'Urbano, Maurizio
AU  - D'Urbano M
LA  - eng
PT  - Journal Article
PT  - Review
PL  - United States
TA  - J Cardiovasc Med (Hagerstown)
JT  - Journal of cardiovascular medicine (Hagerstown, Md.)
JID - 101259752
RN  - 0 (Antithrombins)
RN  - 0 (Hirudins)
RN  - 0 (Peptide Fragments)
RN  - 0 (Recombinant Proteins)
RN  - TN9BEX005G (bivalirudin)
SB  - IM
MH  - Acute Coronary Syndrome/mortality/*therapy
MH  - Antithrombins/adverse effects/*therapeutic use
MH  - *Coronary Artery Bypass/adverse effects/mortality
MH  - Drug Utilization
MH  - Evidence-Based Medicine
MH  - Hemorrhage/chemically induced
MH  - Hirudins/adverse effects
MH  - Humans
MH  - Myocardial Infarction/mortality/*therapy
MH  - Peptide Fragments/adverse effects/*therapeutic use
MH  - *Percutaneous Coronary Intervention/adverse effects/mortality
MH  - Practice Patterns, Physicians'
MH  - Recombinant Proteins/adverse effects/therapeutic use
MH  - Risk Factors
MH  - Time Factors
MH  - Treatment Outcome
EDAT- 2013/02/28 06:00
MHDA- 2014/02/13 06:00
CRDT- 2013/02/28 06:00
PHST- 2013/02/28 06:00 [entrez]
PHST- 2013/02/28 06:00 [pubmed]
PHST- 2014/02/13 06:00 [medline]
AID - 10.2459/JCM.0b013e32835f1915 [doi]
PST - ppublish
SO  - J Cardiovasc Med (Hagerstown). 2013 May;14(5):334-41. doi: 
      10.2459/JCM.0b013e32835f1915.