PMID- 24447496
OWN - NLM
STAT- MEDLINE
DCOM- 20151020
LR  - 20161125
IS  - 1532-8422 (Electronic)
IS  - 1053-0770 (Linking)
VI  - 28
IP  - 4
DP  - 2014 Aug
TI  - Anticoagulation for critically ill cardiac surgery patients: is primary 
      bivalirudin the next step?
PG  - 1013-17
LID - S1053-0770(13)00528-4 [pii]
LID - 10.1053/j.jvca.2013.10.004 [doi]
AB  - OBJECTIVE: Anticoagulation with unfractionated heparin (UFH) in critically ill 
      cardiac surgery patients has several limitations, including the risk of 
      heparin-induced thrombocytopenia. The use of a direct thrombin inhibitor, such as 
      bivalirudin, might either treat this complication or completely eliminate it. The 
      aim of the present study was to analyze the use of bivalirudin in this setting, 
      as either a secondary drug switching from heparin or as the primary 
      anticoagulant, and to evaluate clinical outcomes. DESIGN: Propensity-matching 
      retrospective analysis. SETTING: A cardiac surgery intensive care unit. 
      PARTICIPANTS: One hundred propensity-matched patients who received heparin or 
      bivalirudin. INTERVENTIONS: Bivalirudin was administered as a first-line or 
      second-line drug after heparin discontinuation in case of thrombocytopenia and 
      suspicion of heparin-induced thrombocytopenia. Twenty-six patients (52%) received 
      bivalirudin as a primary anticoagulant, while 24 patients (48%) received 
      bivalirudin after switching from heparin. MEASUREMENTS AND MAIN RESULTS: 
      Bivalirudin treatment was associated with a reduction of major bleeding (p=0.05) 
      compared with the control group. Interestingly, in an intention-to-treat 
      analysis, patients receiving primary bivalirudin showed significant reductions in 
      minor bleeding (p=0.04), and mortality (p=0.01) compared with the secondary 
      bivalirudin group and, similarly, compared with the rest of the study population 
      (UFH and secondary bivalirudin patients, p=0.01 and p=0.05, respectively). 
      Predictors of hospital mortality by multivariate analysis included urgent 
      admission (odds ratio [OR]=2.7; 95 confidence interval [CI], 1.03-7.2; p=0.04), 
      ;septic shock (OR=8.0; 95 CI, 2.26-28.7; p<0.005) and primary therapy with UFH 
      (OR=19.2; 95 CI, 2.2-163.9; p=0.007). CONCLUSIONS: Novel anticoagulant strategies 
      might play a crucial role in critically ill cardiac surgery patients. In a 
      propensity-matched population, results of the present study showed that primary 
      bivalirudin anticoagulation may reduce bleeding complications and mortality.
CI  - (c) 2014 Elsevier Inc. All rights reserved.
FAU - Pappalardo, Federico
AU  - Pappalardo F
AD  - Department of Anesthesia and Intensive Care, Milan, Italy. Electronic address: 
      pappalardo.federico@hsr.it.
FAU - Agracheva, Nataliya
AU  - Agracheva N
AD  - Department of Anesthesia and Intensive Care, Milan, Italy.
FAU - Covello, Remo Daniel
AU  - Covello RD
AD  - Department of Anesthesia and Intensive Care, Milan, Italy.
FAU - Pieri, Marina
AU  - Pieri M
AD  - Department of Anesthesia and Intensive Care, Milan, Italy.
FAU - De Bonis, Michele
AU  - De Bonis M
AD  - Department of Cardiac Surgery San Raffaele Scientific Institute, Milan, Italy.
FAU - Calabro, Maria Grazia
AU  - Calabro MG
AD  - Department of Anesthesia and Intensive Care, Milan, Italy.
FAU - Koster, Andreas
AU  - Koster A
AD  - Institute of Anaesthesiology, Heart and Diabetes Centre, North Rhine-Westphalia 
      Ruhr-University Bochum, Bad Oeyenhausen, Germany.
FAU - Zangrillo, Alberto
AU  - Zangrillo A
AD  - Department of Anesthesia and Intensive Care, Milan, Italy.
LA  - eng
PT  - Journal Article
DEP - 20140118
PL  - United States
TA  - J Cardiothorac Vasc Anesth
JT  - Journal of cardiothoracic and vascular anesthesia
JID - 9110208
RN  - 0 (Antithrombins)
RN  - 0 (Hirudins)
RN  - 0 (Peptide Fragments)
RN  - 0 (Recombinant Proteins)
RN  - TN9BEX005G (bivalirudin)
SB  - IM
MH  - Antithrombins/administration & dosage
MH  - *Cardiac Surgical Procedures
MH  - Critical Illness/mortality/*therapy
MH  - Dose-Response Relationship, Drug
MH  - Female
MH  - Follow-Up Studies
MH  - Hirudins/*administration & dosage
MH  - Humans
MH  - Injections, Intravenous
MH  - Italy/epidemiology
MH  - Male
MH  - Middle Aged
MH  - Peptide Fragments/*administration & dosage
MH  - Postoperative Complications/mortality/*prevention & control
MH  - Propensity Score
MH  - Recombinant Proteins/administration & dosage
MH  - Retrospective Studies
MH  - Survival Rate/trends
MH  - Thrombosis/mortality/*prevention & control
OTO - NOTNLM
OT  - bivalirudin
OT  - cardiac surgery
OT  - heparin
OT  - heparin-induced thrombocytopenia
OT  - mortality
EDAT- 2014/01/23 06:00
MHDA- 2015/10/21 06:00
CRDT- 2014/01/23 06:00
PHST- 2013/08/28 00:00 [received]
PHST- 2014/01/23 06:00 [entrez]
PHST- 2014/01/23 06:00 [pubmed]
PHST- 2015/10/21 06:00 [medline]
AID - S1053-0770(13)00528-4 [pii]
AID - 10.1053/j.jvca.2013.10.004 [doi]
PST - ppublish
SO  - J Cardiothorac Vasc Anesth. 2014 Aug;28(4):1013-17. doi: 
      10.1053/j.jvca.2013.10.004. Epub 2014 Jan 18.