In-hospital outcomes after switching from a bivalirudin- first strategy to an unfractionated heparin-first strategy for percutaneous coronary interventions

Rahul V. Jaswaney, Melissa C. Caughey, Christopher End, Patricia Sudar, Michael Yeung, Prashant Kaul, Joseph S. Rossi, George A. Stouffer, John P. Vavalle


Background: The optimal anticoagulation strategy for percutaneous coronary interventions (PCIs) remains debated. We report outcomes after switching from a bivalirudin-first to an unfractionated heparin (UFH)-first strategy for PCIs in a large academic center.
Methods: Patients undergoing PCI from June 1st 2013–May 31st, 2015 were identified through the National Cardiovascular Data Registry (NCDR), and divided into the “bivalirudin era” (June 2013–July 2014) and the “UFH era” (October 2014–May 2015). Bleeding outcomes were compared using multivariable logistic regression adjusted for potential confounders.
Results: A total of 1,145 patients were identified (bivalirudin era =752, UFH era =393). Radial access for PCI increased over time, and was lower in the bivalirudin era (26% vs. 34%, P<0.05). There were 32 major bleeds (4.3%) in the bivalirudin era and 29 major bleeds (7.4%) in the UFH era (P=0.03), with the majority being hemoglobin drops (≥3 g/dL) without overt clinical bleeding (85.7% of bleeds in the bivalirudin era and 86.2% of bleeds in the UFH era). After adjustments for other common major causes of bleeding, bivalirudin was associated with 78% lower odds of bleeding (OR =0.22; 95% CI: 0.05–0.91).
Conclusions: An increase in major bleeding events occurred after switching to an UFH-first strategy, primarily associated with hemoglobin drop (≥3 g/dL) without overt clinical bleeding. Major overt bleeding was rare (0.3%) and similar in both groups. These results suggest a UFH-first strategy for PCI may have a role in patients with low bleeding risk.