Combined Use of Bivalirudin and Radial Access in ACS

Study Questions:

What is the relation between access site and bivalirudin use on outcomes in patients with acute coronary syndrome (ACS)?

Methods:

This analysis included randomized controlled trials that compared bivalirudin to heparin with or without glycoprotein IIb/IIIa inhibitors in patients with ACS, and reported outcomes stratified by arterial access site. Meta-analyses of outcome data were performed on the basis of access site and anticoagulation regimen. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated from event rates using random-effects models.

Results:

Eight trials with a total of 27,491 patients were included. Bivalirudin reduced major bleeding risk in patients with femoral access (OR, 0.51; 95% CI, 0.46-0.6; p < 0.001), but not in patients with radial access (OR, 0.75; 95% CI, 0.45-1.26; p = 0.28). Moreover, radial access reduced major bleeding risk in patients treated with heparin (OR, 0.57; 95% CI, 0.43-0.77; p < 0.001), but not in patients treated with bivalirudin (OR, 0.96; 95% CI, 0.65-1.41; p = 0.83). There were no differences in major adverse cardiovascular events (MACE) or all-cause mortality between bivalirudin and heparin, regardless of access site.

Conclusions:

The authors concluded that bivalirudin reduces bleeding risk only with femoral access, and radial access reduces bleeding risk only with heparin anticoagulation.

Perspective:

This meta-analysis reports that bivalirudin lowers major bleeding in patients with femoral access, but not in those with radial access; radial access lowers major bleeding in patients treated with heparin, but not in patients treated with bivalirudin; and there is no difference in MACE or all-cause mortality between bivalirudin and heparin with or without glycoprotein inhibitors in patients with femoral access and those with radial access. It appears that the combined use of these two bleeding reducing modalities is not superior to using either one separately. The ongoing SAFARI-STEMI (Femoral Versus Radial Access for Primary PCI) trial comparing outcomes in patients with radial access and those with femoral access with use of either bivalirudin or unfractionated heparin will provide additional insight on this issue.


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