Applications of bivalirudin in interventional cardiology

1. Applications of bivalirudin in interventionalcardiology Giuseppe Biondi Zoccai Divisione di Cardiologia Università di Torino Ospedale S. Giovanni Battista di Torino gbiondizoccai@gmail.com

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 47-YEAR-OLD WOMAN WITH UNSTABLE ANGINA AND HIT Whatis the most appropriate antithromboticregimenfor PCI in patientswith HIT?

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

10. 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

11. 69-YEAR-OLD MAN WITH CSA, SEVERE LVD, PRIOR CABG AND PRIOR STROKE Whatis the most appropriate antithromboticregimenforischemic cardiomyopathy or CSA?

12. ISCHEMIC CARDIOMYOPATHY OR CHRONIC STABLE ANGINA Kastrati et al, New Engl J Med 2008

13. ISCHEMIC CARDIOMYOPATHY OR CHRONIC STABLE ANGINA Kastrati et al, New Engl J Med 2008

14. 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

15. 71-YEAR-OLD WOMAN WITH NSTEMI AND CHRONIC RENAL FAILURE Whatis the most appropriate antithromboticregimenfor NSTEACS?

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

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

18. 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

19. 76-YEAR-OLD WOMAN WITH ST-ELEVATION ACS AND CARDIOGENIC SHOCK Whatis the most appropriate antithromboticregimenfor STEMI?

20. ST-ELEVATION ACS Mehran et al, Lancet 2009

21. ST-ELEVATION ACS Mehran et al, Lancet 2009

22. ST-ELEVATION ACS Mehran et al, Lancet 2009

23. 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

24. 87-YEAR-OLD MAN WITH SEVERE AORTIC STENOSIS AND PROHIBITIVE STS SCORE Whatis the most appropriate antithromboticregimenduring TAVI?

25. 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

26. 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