SEX DIFFERENCES AND CHANGES IN HEALTH STATUS OF YOUNG ADULTS DURING THE FIRST YEAR FOLLOWING ACUTE MYOCARDIAL INFARCTION

Bivalirudin for primary percutaneous coronary interventions in patients with cardiogenic shock: Outcome Assessment in the CAPITAL STEMI registry. BACKGROUND: Data from randomized clinical trials have demonstrated superiority of bivalirudin to heparin with or without routine use of glycoprotein (GP) IIb/IIIa inhibitors in patients undergoing primary percutaneous coronary intervention (PPCI). However the performance of bivalirudin in PPCI without the use GPIIb/IIIa inhibitors, in patients with cardiogenic shock remains unknown. METHODS AND RESULTS: We screened 2536 patients who underwent PPCI for ST elevation myocardial infarction (STEMI) at the University of Ottawa Heart Institute between June 2004 to June 2011. From this cohort, we identified 91 patients who developed cardiogenic shock and who received either bivalirudin (n1⁄434) or Heparin (n1⁄457), with no GP IIb/IIIa inhibitors. The primary outcome was a composite of cardiovascular death, myocardial infarction and stroke. The secondary endpoints were the rate non-coronary artery bypass graft related TIMI major bleeding, any major bleeding, reinfarction and stent thrombosis and in-hospital mortality. The primary outcome was similar in both groups, occurring in 44% of patients receiving bivalirudin vs. 58% in patients treated with heparin alone (OR 0.76 CI 0.36 to 1.60, P1⁄40.47). Compared with the heparin group, a reduction in non-CABG related TIMI major bleeding (18% vs. 16%, P1⁄40.72), any major bleeding (18% vs. 19%, P1⁄40.87) or inhospital mortality (38% vs. 52%, P1⁄40.18) with bivalirudin could not be demonstrated. Notably, the use of bivalirudin was associated with a 6.8 fold increased risk of stent thrombosis and re-infarction (11.7% vs. 1.7%, P1⁄40.043). CONCLUSION: In patients with cardiogenic shock, undergoing PPCI with dual antiplatelet therapy with no GP IIb/IIIa inhibitors, the use of bivalirudin appears to be a safe anticoagulation strategy when compared to heparin. Bivalirudin was however associated with a potential risk of increased stent thrombosis and re-infarction in the setting of cardiogenic shock. Larger clinical studies are needed to either confirm or refute these findings.