Bivalirudin linked to less bleeding, but more severe complications, vs. eptifibatide


At the 18th World Congress on Heart Disease

VANCOUVER, B.C. – Among patients undergoing percutaneous coronary interventions, bivalirudin was associated with significantly fewer bleeding complications than eptifibatide, but bleeding complications were more severe with bivalirudin, according to a retrospective case-cohort study from Mt. Auburn Hospital in Cambridge, Mass.

Investigators compared bleeding complications among 660 angioplasty patients who received bivalirudin (Angiomax) with 345 who received eptifibatide (Integrilin) instead. MIs were the most common indication for intervention.

Dr. Smita Kohli

Just 31 (3%) of those patients had a bleeding episode; 1 patient was excluded for receiving both medications. Of the remaining bleeding cases, 10 were in the bivalirudin group, and 20 were in the eptifibatide group, a significant difference.

However, 7 of those 10 bivalirudin bleeding cases were severe according to GUSTO (Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries) criteria, meaning patients had either intracranial hemorrhages or bleeding that caused hemodynamic compromise and required intervention. One patient had a retroperitoneal bleed that required 10 transfusions and surgical hematoma decompression. Among eptifibatide patients, 7 cases (35%) were severe.

There were three moderate bleeding cases – bleeding that required blood transfusions but did not result in hemodynamic compromise – among bivalirudin patients, and nine in the eptifibatide group, which also had four mild bleeds. For bivalirudin bleeding cases, the average length of hospital stay was 9.6 days; for eptifibatide cases, 8.7 days. Urgent PCI cases were associated with more bleeding complications.

All of the patients were on aspirin, with most also given thienopyridines. About 20% in each group were on warfarin. About 90% of patients on eptifibatide, an antiplatelet drug, were on concomitant heparin, compared with 20% on bivalirudin, itself an anticoagulant.

Bivalirudin is generally thought to cause less bleeding, but "we never looked at the severity of those [bleeds]. Although bivalirudin caused less bleeding, those episodes tended to be much more serious," something that was "unexpected," said lead investigator Dr. Smita Kohli, a cardiology research fellow now at Henry Ford Hospital in Detroit.

Age may have played a role. Eptifibatide bleeders were aged 66 years on average, but bivalirudin bleeders were aged 76 years. Because they were older, maybe they had a greater risk of severe bleeding, Dr. Kohli suggested. Another potential factor – kidney function – did not seem to play a role. Patients in both groups "had similar baseline kidney function," with a mean creatinine level of 1.0 mg/dL, Dr. Kohli said at the 18th World Congress on Heart Disease.

The numbers in the study are small, and "we haven’t really identified what caused those cases to be severe," she said. For now, the findings are more hypothesis generating, not a guide to practice, she added.

Dr. Kohli said she has no disclosures.

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