Heparin plus short-term tirofiban demonstrates less bleeding than bivalirudin during PCI

NEW ORLEANS — The use of heparin plus short-term infusions of tirofiban during elective or urgent PCI demonstrated no significant differences in 30-day bleeding, as well as death, myocardial infarction and urgent target vessel revascularization at 1 year compared with bivalirudin, according to study results presented at the American Heart Association Scientific Sessions.

However, the study results demonstrated that there was a trend toward less bleeding with short-term tirofiban (Aggrastat) when compared with bivalirudin (Angiomax, The Medicines Company).

Joseph B. Muhlestein

Joseph B. Muhlestein, MD, co-director of cardiology research at Intermountain Medical Center in Murray, Utah, and colleagues conducted an observational study from January 2013 to December 2015 of patients who underwent successful PCI without cardiogenic shock and were anticoagulated using either heparin plus short-term tirofiban (n = 402) or bivalirudin (n = 455) to assess the safety and efficacy of each therapy and possibly identify which strategy of anticoagulation during PCI is best.

Muhlestein and colleagues identified that there were no statistical differences between either therapy in 30-day bleeding according to TIMI (adjusted OR = 0.41; 95% CI, 0.14-1.23), 1-year death (aOR = 0.5; 95% CI, 0.13-2), 1-year non-fatal myocardial infarction (aOR = 1.09; 95% CI, 0.24-5.06), and 1-year urgent target vessel revascularization (aOR = 1.23; 95% CI, 0.18-8.44).

“There was no statistical significance between the two groups, but in the situation where you want to use a glycoprotein IIb/IIIa inhibitor - because you want to make sure you inhibit the platelets during the procedure – we feel that we have demonstrated that if you don’t leave it on forever [less than 6 hours], you will have no more bleeding, and maybe even a little less bleeding than if you use bivalirudin,” Muhlestein told Cardiology Today.

Muhlestein said there are a few issues that warrant further investigation. “One is, this was also the time period we sort of evolved: We had been using bivalirudin mostly, and then we evolved and started using short-term glycoprotein IIb/IIIa inhibitors and at that same time of that evolution, we were also evolving more to radial artery procedures,” he said. Muhlestein also noted that patients in the short-term tirofiban group were more likely to undergo radial artery procedures, which may have influenced the reduction of bleeding.

Muhlestein said he plans to conduct a separate analysis that will adjust for patients who underwent radial procedures versus femoral access only.

However, Muhlestein noted he doesn’t expect a significant difference between the two because there wasn’t much bleeding in either cohort.

Muhlestein said “[the results] are a very reassuring thing” and that they indicate that the use of heparin with a short-term glycoprotein IIb/IIIa antagonist seems effective before surgery. – by Ryan McDonald

Reference: Muhlestein JB, et al. S4283. Presented at: American Heart Association Scientific Sessions; Nov. 12-16, 2016; New Orleans.

Disclosure: Muhlestein reports no relevant financial disclosures.