Choice of access site and type of anticoagulant in acute coronary syndromes with advanced Killip class or out-of-hospital cardiac arrest.

Gargiulo, Giuseppe; Valgimigli, Marco; Sunnaker, Mikael; Vranckx, Pascal; Frigoli, Enrico; Leonardi, Sergio; Spirito, Alessandro; Gragnano, Felice; Manavifar, Negar; Galea, Roberto; De Caterina, Alberto R; Calabrò, Paolo; Esposito, Giovanni; Windecker, Stephan; Hunziker Munsch, Lukas (2020). Choice of access site and type of anticoagulant in acute coronary syndromes with advanced Killip class or out-of-hospital cardiac arrest. (In Press). Revista española de cardiología (English ed.) Elsevier 10.1016/j.rec.2020.01.005

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INTRODUCTION AND OBJECTIVES Patients who are vulnerable to hemodynamic or electrical disorders (VP) are often excluded from clinical trials and data on the optimal access-site or antithrombotic treatment are limited. We assessed outcomes of transradial vs transfemoral access and bivalirudin vs unfractionated heparin (UFH) in VP with acute coronary syndrome undergoing invasive management. METHODS The MATRIX trial randomized 8404 patients to radial or femoral access and 7213 patients to bivalirudin or UFH. Among them, 934 (11.1%) were deemed VP due to advanced Killip class (n = 808), cardiac arrest (n = 168), or both (n = 42). The 30-day coprimary outcomes were major adverse cardiovascular and cerebrovascular events (MACE: death, myocardial infarction, or stroke) and net adverse clinical events (NACE: MACE or major bleeding). RESULTS MACE and NACE were similarly reduced with radial vs femoral access in VP and non-VP. Transradial access was also associated with consistent relative benefits in all-cause and cardiovascular mortality or Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding with greater absolute benefits in VP. The effects of bivalirudin vs UFH on MACE and NACE were consistent in VP and non-VP. Bivalirudin was associated with lower all-cause and cardiovascular mortality in VP but not in non-VP, with borderline interaction testing. Bivalirudin reduced bleeding in both VP and non-VP with a larger absolute benefit in VP. CONCLUSIONS In acute coronary syndrome patients undergoing invasive management, the effects of randomized treatments were consistent in VP and non-VP, but absolute risk reduction with radial access and bivalirudin were greater in VP, with a 5- to 10-fold lower number needed to treat for benefits. Trial registry number: NCT01433627.

Item Type:

Journal Article (Original Article)

Division/Institute:

04 Faculty of Medicine > Department of Cardiovascular Disorders (DHGE) > Clinic of Cardiology
04 Faculty of Medicine > Pre-clinic Human Medicine > CTU Bern

UniBE Contributor:

Gargiulo, Giuseppe; Valgimigli, Marco; Sunnaker, Mikael Anders; Frigoli, Enrico; Spirito, Alessandro; Manavifar, Negar; Galea, Roberto; Windecker, Stephan and Hunziker Munsch, Lukas Christoph

Subjects:

600 Technology > 610 Medicine & health

ISSN:

1885-5857

Publisher:

Elsevier

Language:

English

Submitter:

Andrea Flükiger-Flückiger

Date Deposited:

18 Mar 2020 12:40

Last Modified:

02 Apr 2020 13:09

Publisher DOI:

10.1016/j.rec.2020.01.005

PubMed ID:

32151464

Uncontrolled Keywords:

Acceso radial Acute coronary syndrome Acute heart failure Bivalirudin Bivalirudina Cardiac arrest Insuficiencia cardiaca aguda Paciente vulnerable Parada cardiaca Radial access Síndrome coronario agudo Vulnerable patients

BORIS DOI:

10.7892/boris.141941

URI:

https://boris.unibe.ch/id/eprint/141941

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