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Applications of bivalirudin in interventional cardiology. Giuseppe Biondi Zoccai Divisione di Cardiologia Università di Torino Ospedale S. Giovanni Battista di Torino gbiondizoccai@gmail.com. LEARNING GOALS. SCOPE OF THE PROBLEM TREATMENT ALTERNATIVES POTENTIAL CLINICAL USES

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applications of bivalirudin in interventional cardiology

Applications of bivalirudin in interventionalcardiology

Giuseppe Biondi Zoccai

Divisione di Cardiologia

Università di Torino

Ospedale S. Giovanni Battista di Torino

gbiondizoccai@gmail.com

learning goals
LEARNING GOALS
  • SCOPE OF THE PROBLEM
  • TREATMENT ALTERNATIVES
  • POTENTIAL CLINICAL USES
    • Heparin-induced thrombocytopenia
    • Ischemic cardiomyopathy
    • Chronic stable angina
    • Non-ST-elevation acute coronary syndromes
    • ST-elevation acute coronary syndromes
    • Transcatheter aortic valve implantation
scope of the problem

Major Bleed only (without MI) (N=551)

12.5%

MI only (without Major Bleed) (N=611)

8.6%

No MI or Major Bleed (N=12,557)

Both MI and Major Bleed (N=94)

28.9%

3.4%

SCOPE OF THE PROBLEM

Impact of MI and major bleeding in the first

30 days on 1-year mortality in ACUITY

learning goals1
LEARNING GOALS
  • SCOPE OF THE PROBLEM
  • TREATMENT ALTERNATIVES
  • POTENTIAL CLINICAL USES
    • Heparin-induced thrombocytopenia
    • Ischemic cardiomyopathy
    • Chronic stable angina
    • Non-ST-elevation acute coronary syndromes
    • ST-elevation acute coronary syndromes
    • Transcatheter aortic valve implantation
treatment alternatives

Aspirin

Clopidogrel

Prasugrel

Ticagrelor

LMWH

Heparin

GPIIb/IIIa

inhibitors

Bivalirudin

Hirudin

Argatroban

Thrombo-

lytics

TREATMENT ALTERNATIVES

Coagulation

cascade

Platelet

cascade

Tissue factor

Collagen

Plasma clotting

cascade

ADP

Thromboxane A2

Prothrombin

AT

Factor

Xa

Conformational activation of GPIIb/IIIa

AT

Thrombin

Platelet aggregation

Fibrinogen

Fibrin

Thrombus

treatment alternatives1
TREATMENT ALTERNATIVES

Renal function

Age

Elderly: ???

Normal: Enox, Bival, Fonda, UFH

CKD: Bival, UFH

Bleeding Risk

Cost

Low: Enox, UFH, Bival

Mod: Bival, Fonda, UFH

High: Bival, Fonda, UFH

Enox, UFH

Fonda, Bival?

Ease of use

Ischemic Risk

Enox, Bival, Fonda

Low: Enox, Bival, UFH

Mod: Enox, Bival, UFH

High: Enox, Fonda, Bival

PCI vs CABG vs Med Rx

Time to Cath

PCI: Enox, Bival, UFH

CABG: UFH

Med Rx: Enox, Fonda, Bival

Rapid: Bival, UFH

Early: Enox, UFH, Bival

Delayed: Enox

learning goals2
LEARNING GOALS
  • SCOPE OF THE PROBLEM
  • TREATMENT ALTERNATIVES
  • POTENTIAL CLINICAL USES
    • Heparin-induced thrombocytopenia
    • Ischemic cardiomyopathy
    • Chronic stable angina
    • Non-ST-elevation acute coronary syndromes
    • ST-elevation acute coronary syndromes
    • Transcatheter aortic valve implantation
47 year old woman with unstable angina and hit
47-YEAR-OLD WOMAN WITH UNSTABLE ANGINA AND HIT

Whatis the most appropriate antithromboticregimenfor PCI in patientswith HIT?

heparin induced thrombocytopenia
HEPARIN-INDUCED THROMBOCYTOPENIA

The Anticoagulant Therapy with Bivalirudin to Assist in the performance of PCI in patients with heparin-induced Thrombocytopenia (ATBAT) trial

learning goals3
LEARNING GOALS
  • SCOPE OF THE PROBLEM
  • TREATMENT ALTERNATIVES
  • POTENTIAL CLINICAL USES
    • Heparin-induced thrombocytopenia
    • Ischemic cardiomyopathy
    • Chronic stable angina
    • Non-ST-elevation acute coronary syndromes
    • ST-elevation acute coronary syndromes
    • Transcatheter aortic valve implantation
69 year old man with csa severe lvd prior cabg and prior stroke
69-YEAR-OLD MAN WITH CSA, SEVERE LVD, PRIOR CABG AND PRIOR STROKE

Whatis the most appropriate antithromboticregimenforischemic cardiomyopathy or CSA?

ischemic cardiomyopathy or chronic stable angina
ISCHEMIC CARDIOMYOPATHY OR CHRONIC STABLE ANGINA

Kastrati et al, New Engl J Med 2008

ischemic cardiomyopathy or chronic stable angina1
ISCHEMIC CARDIOMYOPATHY OR CHRONIC STABLE ANGINA

Kastrati et al, New Engl J Med 2008

learning goals4
LEARNING GOALS
  • SCOPE OF THE PROBLEM
  • TREATMENT ALTERNATIVES
  • POTENTIAL CLINICAL USES
    • Heparin-induced thrombocytopenia
    • Ischemic cardiomyopathy
    • Chronic stable angina
    • Non-ST-elevation acute coronary syndromes
    • ST-elevation acute coronary syndromes
    • Transcatheter aortic valve implantation
71 year old woman with nstemi and chronic renal failure
71-YEAR-OLD WOMAN WITH NSTEMI AND CHRONIC RENAL FAILURE

Whatis the most appropriate antithromboticregimenfor NSTEACS?

nsteacs
NSTEACS

1-month rate of major adverse cardiac events in the ACUITY trial

nsteacs1
NSTEACS

1-month rate of net clinical adverse events in the ACUITY trial

learning goals5
LEARNING GOALS
  • SCOPE OF THE PROBLEM
  • TREATMENT ALTERNATIVES
  • POTENTIAL CLINICAL USES
    • Heparin-induced thrombocytopenia
    • Ischemic cardiomyopathy
    • Chronic stable angina
    • Non-ST-elevation acute coronary syndromes
    • ST-elevation acute coronary syndromes
    • Transcatheter aortic valve implantation
76 year old woman with st elevation acs and cardiogenic shock
76-YEAR-OLD WOMAN WITH ST-ELEVATION ACS AND CARDIOGENIC SHOCK

Whatis the most appropriate antithromboticregimenfor STEMI?

st elevation acs
ST-ELEVATION ACS

Mehran et al, Lancet 2009

st elevation acs1
ST-ELEVATION ACS

Mehran et al, Lancet 2009

st elevation acs2
ST-ELEVATION ACS

Mehran et al, Lancet 2009

learning goals6
LEARNING GOALS
  • SCOPE OF THE PROBLEM
  • TREATMENT ALTERNATIVES
  • POTENTIAL CLINICAL USES
    • Heparin-induced thrombocytopenia
    • Ischemic cardiomyopathy
    • Chronic stable angina
    • Non-ST-elevation acute coronary syndromes
    • ST-elevation acute coronary syndromes
    • Transcatheter aortic valve implantation
87 year old man with severe aortic stenosis and prohibitive sts score
87-YEAR-OLD MAN WITH SEVERE AORTIC STENOSIS AND PROHIBITIVE STS SCORE

Whatis the most appropriate antithromboticregimenduring TAVI?

take home messages
TAKE HOME MESSAGES
  • The interventional cardiologist is challenged every day by the quest for an optimal balance between preventing bleeding and thrombosis
  • Several alternative parenteral antithrombotic drugs are available, with a significantly different efficacy and safety profile
  • Bivalirudin may represent an effective and safe alternative in several clinical settings, especially when there is moderate or high risk for bleeding
slide26

Thank you for your attentionFor any correspondence: gbiondizoccai@gmail.comFor these and further slides on these topics feel free to visit the metcardio.org website:http://www.metcardio.org/slides.html