Anticoagulant therapy during primary percutaneous coronary intervention for acute myocardial infarction: a meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors
Objectives To investigate the relative benefits of unfractionated heparin, low molecular weight heparin(LMWH), fondaparinux, and bivalirudin as treatment options for patients with ST segment elevation myocardial infarction undergoing percutaneous coronary intervention (PCI).Design Mixed treatment co...
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| Veröffentlicht in: | BMJ (Online) 2014-11, Vol.349 (nov11 4), p.g6419-g6419 |
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| creator | Bangalore, Sripal Toklu, Bora Kotwal, Anupam Volodarskiy, Alexander Sharma, Sahil Kirtane, Ajay J Feit, Frederick |
| description | Objectives To investigate the relative benefits of unfractionated heparin, low molecular weight heparin(LMWH), fondaparinux, and bivalirudin as treatment options for patients with ST segment elevation myocardial infarction undergoing percutaneous coronary intervention (PCI).Design Mixed treatment comparison and direct comparison meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors.Data sources and study selection A search of Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) for randomized trials comparing unfractionated heparin plus glycoprotein IIb/IIIa inhibitor(GpIIb/IIIa inhibitor), unfractionated heparin, bivalirudin, fondaparinux, or LMWH plus GpIIb/IIIa inhibitor for patients undergoing primary PCI.Outcomes The primary efficacy outcome was short term (in hospital or within 30 days) major adverse cardiovascular event; the primary safety outcome was short term major bleeding.Results We identified 22 randomized trials that enrolled 22 434 patients. In the mixed treatment comparison models, when compared with unfractionated heparin plus GpIIb/IIIa inhibitor, unfractionated heparin was associated with a higher risk of major adverse cardiovascular events (relative risk 1.49 (95% confidence interval 1.21 to 1.84), as were bivalirudin (relative risk 1.34 (1.01 to 1.78)) and fondaparinux (1.78 (1.01 to 3.14)). LMWH plus GpIIb/IIIa inhibitor showed highest treatment efficacy, followed (in order) by unfractionated heparin plus GpIIb/IIIa inhibitor, bivalirudin, unfractionated heparin, and fondaparinux. Bivalirudin was associated with lower major bleeding risk compared with unfractionated heparin plus GpIIb/IIIa inhibitor (relative risk 0.47 (0.30 to 0.74)) or unfractionated heparin (0.58 (0.37 to 0.90)). Bivalirudin, followed by unfractionated heparin, LMWH plus GpIIb/IIIa inhibitor, unfractionated heparin plus GpIIb/IIIa inhibitor, and fondaparinux were the hierarchy for treatment safety. Results were similar in direct comparison meta-analyses: bivalirudin was associated with a 39%, 44%, and 65% higher risk of myocardial infarction, urgent revascularization, and stent thrombosis respectively when compared with unfractionated heparin with or without GpIIb/IIIa inhibitor. However, bivalirudin was associated with a 48% lower risk of major bleeding compared with unfractionated heparin plus GpIIb/IIIa inhibitor and 32% lower compared with unfractionated heparin alone.Conclusions In patients undergoing primary PCI, un |
| doi_str_mv | 10.1136/bmj.g6419 |
| format | Article |
| fullrecord | <record><control><sourceid>jstor_pubme</sourceid><recordid>TN_cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_4227311</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><jstor_id>26518525</jstor_id><sourcerecordid>26518525</sourcerecordid><originalsourceid>FETCH-LOGICAL-b548t-3297d67a73fd5736b586f49e36c1228a38c9be8dd4a77963873ebb3aed77efd53</originalsourceid><addsrcrecordid>eNp9kstu1DAUhi0EoqOhCx4AZAkWZZES24kvXSBVFTepEixgwcpyEmfGo8QebKfS8GK8Xk_IUC4SeGPJ_3d-H_8-CD0m5TkhjL9sxt35hldE3UMrImpeEMnYfbQqVa0KSZg8Qacp7cqypExIxeuH6ITWTCpSsRX6fumza4PZTIPxGeetjWZ_wN0Und_gfXSjiQe8t7GdsvE2TAm3IQY_nzqfbbyxYBA87kPEBiCLx0NoTeycGYDoTWxn_QIbPNpsCuPNcEgu4dDjaHwXRvfNdjhH4BMUzC1gaGLWUwbzhIHCH-kXQkHeusblENMj9KCHAnt63Nfo85vXn67eFdcf3r6_urwumrqSuWBUiY4LI1jf1YLxppa8r5RlvCWUSsNkqxoru64yQijOpGC2aZixnRAWStgavVp891Mz2q6FhqIZ9DEYHYzTfyrebfUm3OiKUsHgg9bo7GgQw9fJpqxHl1o7DEuamnBaKUYZLQF99he6C1OEvIASsBQtCf0vxVklKC0pB-rFQrUxpBRtf9cyKfU8NxrmRv-YG2Cf_v7GO_LnlADwZAF2CbL_pfOayJrOIT1f9Nnz3_fcAo8G1-Y</addsrcrecordid><sourcetype>Open Access Repository</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>1777792012</pqid></control><display><type>article</type><title>Anticoagulant therapy during primary percutaneous coronary intervention for acute myocardial infarction: a meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors</title><source>MEDLINE</source><source>BMJ Journals - NESLi2</source><source>Applied Social Sciences Index & Abstracts (ASSIA)</source><source>JSTOR Archive Collection A-Z Listing</source><creator>Bangalore, Sripal ; Toklu, Bora ; Kotwal, Anupam ; Volodarskiy, Alexander ; Sharma, Sahil ; Kirtane, Ajay J ; Feit, Frederick</creator><creatorcontrib>Bangalore, Sripal ; Toklu, Bora ; Kotwal, Anupam ; Volodarskiy, Alexander ; Sharma, Sahil ; Kirtane, Ajay J ; Feit, Frederick</creatorcontrib><description>Objectives To investigate the relative benefits of unfractionated heparin, low molecular weight heparin(LMWH), fondaparinux, and bivalirudin as treatment options for patients with ST segment elevation myocardial infarction undergoing percutaneous coronary intervention (PCI).Design Mixed treatment comparison and direct comparison meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors.Data sources and study selection A search of Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) for randomized trials comparing unfractionated heparin plus glycoprotein IIb/IIIa inhibitor(GpIIb/IIIa inhibitor), unfractionated heparin, bivalirudin, fondaparinux, or LMWH plus GpIIb/IIIa inhibitor for patients undergoing primary PCI.Outcomes The primary efficacy outcome was short term (in hospital or within 30 days) major adverse cardiovascular event; the primary safety outcome was short term major bleeding.Results We identified 22 randomized trials that enrolled 22 434 patients. In the mixed treatment comparison models, when compared with unfractionated heparin plus GpIIb/IIIa inhibitor, unfractionated heparin was associated with a higher risk of major adverse cardiovascular events (relative risk 1.49 (95% confidence interval 1.21 to 1.84), as were bivalirudin (relative risk 1.34 (1.01 to 1.78)) and fondaparinux (1.78 (1.01 to 3.14)). LMWH plus GpIIb/IIIa inhibitor showed highest treatment efficacy, followed (in order) by unfractionated heparin plus GpIIb/IIIa inhibitor, bivalirudin, unfractionated heparin, and fondaparinux. Bivalirudin was associated with lower major bleeding risk compared with unfractionated heparin plus GpIIb/IIIa inhibitor (relative risk 0.47 (0.30 to 0.74)) or unfractionated heparin (0.58 (0.37 to 0.90)). Bivalirudin, followed by unfractionated heparin, LMWH plus GpIIb/IIIa inhibitor, unfractionated heparin plus GpIIb/IIIa inhibitor, and fondaparinux were the hierarchy for treatment safety. Results were similar in direct comparison meta-analyses: bivalirudin was associated with a 39%, 44%, and 65% higher risk of myocardial infarction, urgent revascularization, and stent thrombosis respectively when compared with unfractionated heparin with or without GpIIb/IIIa inhibitor. However, bivalirudin was associated with a 48% lower risk of major bleeding compared with unfractionated heparin plus GpIIb/IIIa inhibitor and 32% lower compared with unfractionated heparin alone.Conclusions In patients undergoing primary PCI, unfractionated heparin plus GpIIb/IIIa inhibitor and LMWH plus GpIIb/IIIa inhibitor were most efficacious, with the lowest rate of major adverse cardiovascular events, whereas bivalirudin was safest, with the lowest bleeding. These relationships should be considered in selecting anticoagulant therapies in patients undergoing primary PCI.</description><edition>International edition</edition><identifier>ISSN: 0959-8138</identifier><identifier>ISSN: 1756-1833</identifier><identifier>ISSN: 0959-8146</identifier><identifier>EISSN: 1756-1833</identifier><identifier>DOI: 10.1136/bmj.g6419</identifier><identifier>PMID: 25389143</identifier><identifier>CODEN: BMJOAE</identifier><language>eng</language><publisher>England: British Medical Journal Publishing Group</publisher><subject>Angioplasty ; Anticoagulants ; Anticoagulants - adverse effects ; Anticoagulants - therapeutic use ; Antithrombins - adverse effects ; Antithrombins - therapeutic use ; Bias ; Cardiology ; Estimates ; Heart attacks ; Hemorrhage - chemically induced ; Heparin - adverse effects ; Heparin - therapeutic use ; Heparin, Low-Molecular-Weight - adverse effects ; Heparin, Low-Molecular-Weight - therapeutic use ; Hirudins - adverse effects ; Humans ; Integrin beta3 ; Intervention ; Ischemia ; Meta-analysis ; Myocardial Infarction - therapy ; Peptide Fragments - adverse effects ; Peptide Fragments - therapeutic use ; Percutaneous Coronary Intervention ; Platelet Glycoprotein GPIIb-IIIa Complex - antagonists & inhibitors ; Polysaccharides - therapeutic use ; Purinergic P2Y Receptor Antagonists - therapeutic use ; Recombinant Proteins - adverse effects ; Recombinant Proteins - therapeutic use ; Stents - adverse effects ; Therapy ; Thrombosis - etiology ; Thrombosis - prevention & control ; Treatment Outcome</subject><ispartof>BMJ (Online), 2014-11, Vol.349 (nov11 4), p.g6419-g6419</ispartof><rights>Bangalore et al 2014</rights><rights>Bangalore et al 2014.</rights><rights>Copyright BMJ Publishing Group Nov 15, 2014</rights><rights>Copyright BMJ Publishing Group LTD Nov 11, 2014</rights><rights>Bangalore et al 2014 2014 Bangalore et al</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-b548t-3297d67a73fd5736b586f49e36c1228a38c9be8dd4a77963873ebb3aed77efd53</citedby></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttp://bmj.com/content/349/bmj.g6419.full.pdf$$EPDF$$P50$$Gbmj$$Hfree_for_read</linktopdf><linktohtml>$$Uhttp://bmj.com/content/349/bmj.g6419.full$$EHTML$$P50$$Gbmj$$Hfree_for_read</linktohtml><link.rule.ids>114,115,230,314,780,784,803,885,3194,23570,27923,27924,30998,58016,58249,77371,77402</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/25389143$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Bangalore, Sripal</creatorcontrib><creatorcontrib>Toklu, Bora</creatorcontrib><creatorcontrib>Kotwal, Anupam</creatorcontrib><creatorcontrib>Volodarskiy, Alexander</creatorcontrib><creatorcontrib>Sharma, Sahil</creatorcontrib><creatorcontrib>Kirtane, Ajay J</creatorcontrib><creatorcontrib>Feit, Frederick</creatorcontrib><title>Anticoagulant therapy during primary percutaneous coronary intervention for acute myocardial infarction: a meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors</title><title>BMJ (Online)</title><addtitle>BMJ</addtitle><description>Objectives To investigate the relative benefits of unfractionated heparin, low molecular weight heparin(LMWH), fondaparinux, and bivalirudin as treatment options for patients with ST segment elevation myocardial infarction undergoing percutaneous coronary intervention (PCI).Design Mixed treatment comparison and direct comparison meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors.Data sources and study selection A search of Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) for randomized trials comparing unfractionated heparin plus glycoprotein IIb/IIIa inhibitor(GpIIb/IIIa inhibitor), unfractionated heparin, bivalirudin, fondaparinux, or LMWH plus GpIIb/IIIa inhibitor for patients undergoing primary PCI.Outcomes The primary efficacy outcome was short term (in hospital or within 30 days) major adverse cardiovascular event; the primary safety outcome was short term major bleeding.Results We identified 22 randomized trials that enrolled 22 434 patients. In the mixed treatment comparison models, when compared with unfractionated heparin plus GpIIb/IIIa inhibitor, unfractionated heparin was associated with a higher risk of major adverse cardiovascular events (relative risk 1.49 (95% confidence interval 1.21 to 1.84), as were bivalirudin (relative risk 1.34 (1.01 to 1.78)) and fondaparinux (1.78 (1.01 to 3.14)). LMWH plus GpIIb/IIIa inhibitor showed highest treatment efficacy, followed (in order) by unfractionated heparin plus GpIIb/IIIa inhibitor, bivalirudin, unfractionated heparin, and fondaparinux. Bivalirudin was associated with lower major bleeding risk compared with unfractionated heparin plus GpIIb/IIIa inhibitor (relative risk 0.47 (0.30 to 0.74)) or unfractionated heparin (0.58 (0.37 to 0.90)). Bivalirudin, followed by unfractionated heparin, LMWH plus GpIIb/IIIa inhibitor, unfractionated heparin plus GpIIb/IIIa inhibitor, and fondaparinux were the hierarchy for treatment safety. Results were similar in direct comparison meta-analyses: bivalirudin was associated with a 39%, 44%, and 65% higher risk of myocardial infarction, urgent revascularization, and stent thrombosis respectively when compared with unfractionated heparin with or without GpIIb/IIIa inhibitor. However, bivalirudin was associated with a 48% lower risk of major bleeding compared with unfractionated heparin plus GpIIb/IIIa inhibitor and 32% lower compared with unfractionated heparin alone.Conclusions In patients undergoing primary PCI, unfractionated heparin plus GpIIb/IIIa inhibitor and LMWH plus GpIIb/IIIa inhibitor were most efficacious, with the lowest rate of major adverse cardiovascular events, whereas bivalirudin was safest, with the lowest bleeding. These relationships should be considered in selecting anticoagulant therapies in patients undergoing primary PCI.</description><subject>Angioplasty</subject><subject>Anticoagulants</subject><subject>Anticoagulants - adverse effects</subject><subject>Anticoagulants - therapeutic use</subject><subject>Antithrombins - adverse effects</subject><subject>Antithrombins - therapeutic use</subject><subject>Bias</subject><subject>Cardiology</subject><subject>Estimates</subject><subject>Heart attacks</subject><subject>Hemorrhage - chemically induced</subject><subject>Heparin - adverse effects</subject><subject>Heparin - therapeutic use</subject><subject>Heparin, Low-Molecular-Weight - adverse effects</subject><subject>Heparin, Low-Molecular-Weight - therapeutic use</subject><subject>Hirudins - adverse effects</subject><subject>Humans</subject><subject>Integrin beta3</subject><subject>Intervention</subject><subject>Ischemia</subject><subject>Meta-analysis</subject><subject>Myocardial Infarction - therapy</subject><subject>Peptide Fragments - adverse effects</subject><subject>Peptide Fragments - therapeutic use</subject><subject>Percutaneous Coronary Intervention</subject><subject>Platelet Glycoprotein GPIIb-IIIa Complex - antagonists & inhibitors</subject><subject>Polysaccharides - therapeutic use</subject><subject>Purinergic P2Y Receptor Antagonists - therapeutic use</subject><subject>Recombinant Proteins - adverse effects</subject><subject>Recombinant Proteins - therapeutic use</subject><subject>Stents - adverse effects</subject><subject>Therapy</subject><subject>Thrombosis - etiology</subject><subject>Thrombosis - prevention & control</subject><subject>Treatment Outcome</subject><issn>0959-8138</issn><issn>1756-1833</issn><issn>0959-8146</issn><issn>1756-1833</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2014</creationdate><recordtype>article</recordtype><sourceid>9YT</sourceid><sourceid>ACMMV</sourceid><sourceid>EIF</sourceid><sourceid>7QJ</sourceid><sourceid>8G5</sourceid><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>AZQEC</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><sourceid>DWQXO</sourceid><sourceid>GNUQQ</sourceid><sourceid>GUQSH</sourceid><sourceid>M2O</sourceid><recordid>eNp9kstu1DAUhi0EoqOhCx4AZAkWZZES24kvXSBVFTepEixgwcpyEmfGo8QebKfS8GK8Xk_IUC4SeGPJ_3d-H_8-CD0m5TkhjL9sxt35hldE3UMrImpeEMnYfbQqVa0KSZg8Qacp7cqypExIxeuH6ITWTCpSsRX6fumza4PZTIPxGeetjWZ_wN0Und_gfXSjiQe8t7GdsvE2TAm3IQY_nzqfbbyxYBA87kPEBiCLx0NoTeycGYDoTWxn_QIbPNpsCuPNcEgu4dDjaHwXRvfNdjhH4BMUzC1gaGLWUwbzhIHCH-kXQkHeusblENMj9KCHAnt63Nfo85vXn67eFdcf3r6_urwumrqSuWBUiY4LI1jf1YLxppa8r5RlvCWUSsNkqxoru64yQijOpGC2aZixnRAWStgavVp891Mz2q6FhqIZ9DEYHYzTfyrebfUm3OiKUsHgg9bo7GgQw9fJpqxHl1o7DEuamnBaKUYZLQF99he6C1OEvIASsBQtCf0vxVklKC0pB-rFQrUxpBRtf9cyKfU8NxrmRv-YG2Cf_v7GO_LnlADwZAF2CbL_pfOayJrOIT1f9Nnz3_fcAo8G1-Y</recordid><startdate>20141111</startdate><enddate>20141111</enddate><creator>Bangalore, Sripal</creator><creator>Toklu, Bora</creator><creator>Kotwal, Anupam</creator><creator>Volodarskiy, Alexander</creator><creator>Sharma, Sahil</creator><creator>Kirtane, Ajay J</creator><creator>Feit, Frederick</creator><general>British Medical Journal Publishing Group</general><general>BMJ Publishing Group</general><general>BMJ Publishing Group LTD</general><general>BMJ Publishing Group Ltd</general><scope>9YT</scope><scope>ACMMV</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7QJ</scope><scope>3V.</scope><scope>7RV</scope><scope>7X7</scope><scope>7XB</scope><scope>88I</scope><scope>8AF</scope><scope>8FE</scope><scope>8FH</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>8G5</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>ASE</scope><scope>AZQEC</scope><scope>BBNVY</scope><scope>BENPR</scope><scope>BHPHI</scope><scope>BTHHO</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FPQ</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>GUQSH</scope><scope>HCIFZ</scope><scope>K6X</scope><scope>K9.</scope><scope>KB0</scope><scope>LK8</scope><scope>M2O</scope><scope>M2P</scope><scope>M7P</scope><scope>MBDVC</scope><scope>NAPCQ</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>Q9U</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>20141111</creationdate><title>Anticoagulant therapy during primary percutaneous coronary intervention for acute myocardial infarction: a meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors</title><author>Bangalore, Sripal ; Toklu, Bora ; Kotwal, Anupam ; Volodarskiy, Alexander ; Sharma, Sahil ; Kirtane, Ajay J ; Feit, Frederick</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-b548t-3297d67a73fd5736b586f49e36c1228a38c9be8dd4a77963873ebb3aed77efd53</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2014</creationdate><topic>Angioplasty</topic><topic>Anticoagulants</topic><topic>Anticoagulants - adverse effects</topic><topic>Anticoagulants - therapeutic use</topic><topic>Antithrombins - adverse effects</topic><topic>Antithrombins - therapeutic use</topic><topic>Bias</topic><topic>Cardiology</topic><topic>Estimates</topic><topic>Heart attacks</topic><topic>Hemorrhage - chemically induced</topic><topic>Heparin - adverse effects</topic><topic>Heparin - therapeutic use</topic><topic>Heparin, Low-Molecular-Weight - adverse effects</topic><topic>Heparin, Low-Molecular-Weight - therapeutic use</topic><topic>Hirudins - adverse effects</topic><topic>Humans</topic><topic>Integrin beta3</topic><topic>Intervention</topic><topic>Ischemia</topic><topic>Meta-analysis</topic><topic>Myocardial Infarction - therapy</topic><topic>Peptide Fragments - adverse effects</topic><topic>Peptide Fragments - therapeutic use</topic><topic>Percutaneous Coronary Intervention</topic><topic>Platelet Glycoprotein GPIIb-IIIa Complex - antagonists & inhibitors</topic><topic>Polysaccharides - therapeutic use</topic><topic>Purinergic P2Y Receptor Antagonists - therapeutic use</topic><topic>Recombinant Proteins - adverse effects</topic><topic>Recombinant Proteins - therapeutic use</topic><topic>Stents - adverse effects</topic><topic>Therapy</topic><topic>Thrombosis - etiology</topic><topic>Thrombosis - prevention & control</topic><topic>Treatment Outcome</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Bangalore, Sripal</creatorcontrib><creatorcontrib>Toklu, Bora</creatorcontrib><creatorcontrib>Kotwal, Anupam</creatorcontrib><creatorcontrib>Volodarskiy, Alexander</creatorcontrib><creatorcontrib>Sharma, Sahil</creatorcontrib><creatorcontrib>Kirtane, Ajay J</creatorcontrib><creatorcontrib>Feit, Frederick</creatorcontrib><collection>BMJ Open Access Journals</collection><collection>BMJ Journals:Open Access</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Applied Social Sciences Index & Abstracts (ASSIA)</collection><collection>ProQuest Central (Corporate)</collection><collection>Nursing & Allied Health Database</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Science Database (Alumni Edition)</collection><collection>STEM Database</collection><collection>ProQuest SciTech Collection</collection><collection>ProQuest Natural Science Collection</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>Research Library (Alumni Edition)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>British Nursing Index</collection><collection>ProQuest Central Essentials</collection><collection>Biological Science Collection</collection><collection>ProQuest Central</collection><collection>Natural Science Collection</collection><collection>BMJ Journals</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>British Nursing Index (BNI) (1985 to Present)</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>Research Library Prep</collection><collection>SciTech Premium Collection</collection><collection>British Nursing Index</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>ProQuest Biological Science Collection</collection><collection>Research Library</collection><collection>Science Database</collection><collection>Biological Science Database</collection><collection>Research Library (Corporate)</collection><collection>Nursing & Allied Health Premium</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>ProQuest Central Basic</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>BMJ (Online)</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Bangalore, Sripal</au><au>Toklu, Bora</au><au>Kotwal, Anupam</au><au>Volodarskiy, Alexander</au><au>Sharma, Sahil</au><au>Kirtane, Ajay J</au><au>Feit, Frederick</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Anticoagulant therapy during primary percutaneous coronary intervention for acute myocardial infarction: a meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors</atitle><jtitle>BMJ (Online)</jtitle><addtitle>BMJ</addtitle><date>2014-11-11</date><risdate>2014</risdate><volume>349</volume><issue>nov11 4</issue><spage>g6419</spage><epage>g6419</epage><pages>g6419-g6419</pages><issn>0959-8138</issn><issn>1756-1833</issn><issn>0959-8146</issn><eissn>1756-1833</eissn><coden>BMJOAE</coden><abstract>Objectives To investigate the relative benefits of unfractionated heparin, low molecular weight heparin(LMWH), fondaparinux, and bivalirudin as treatment options for patients with ST segment elevation myocardial infarction undergoing percutaneous coronary intervention (PCI).Design Mixed treatment comparison and direct comparison meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors.Data sources and study selection A search of Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) for randomized trials comparing unfractionated heparin plus glycoprotein IIb/IIIa inhibitor(GpIIb/IIIa inhibitor), unfractionated heparin, bivalirudin, fondaparinux, or LMWH plus GpIIb/IIIa inhibitor for patients undergoing primary PCI.Outcomes The primary efficacy outcome was short term (in hospital or within 30 days) major adverse cardiovascular event; the primary safety outcome was short term major bleeding.Results We identified 22 randomized trials that enrolled 22 434 patients. In the mixed treatment comparison models, when compared with unfractionated heparin plus GpIIb/IIIa inhibitor, unfractionated heparin was associated with a higher risk of major adverse cardiovascular events (relative risk 1.49 (95% confidence interval 1.21 to 1.84), as were bivalirudin (relative risk 1.34 (1.01 to 1.78)) and fondaparinux (1.78 (1.01 to 3.14)). LMWH plus GpIIb/IIIa inhibitor showed highest treatment efficacy, followed (in order) by unfractionated heparin plus GpIIb/IIIa inhibitor, bivalirudin, unfractionated heparin, and fondaparinux. Bivalirudin was associated with lower major bleeding risk compared with unfractionated heparin plus GpIIb/IIIa inhibitor (relative risk 0.47 (0.30 to 0.74)) or unfractionated heparin (0.58 (0.37 to 0.90)). Bivalirudin, followed by unfractionated heparin, LMWH plus GpIIb/IIIa inhibitor, unfractionated heparin plus GpIIb/IIIa inhibitor, and fondaparinux were the hierarchy for treatment safety. Results were similar in direct comparison meta-analyses: bivalirudin was associated with a 39%, 44%, and 65% higher risk of myocardial infarction, urgent revascularization, and stent thrombosis respectively when compared with unfractionated heparin with or without GpIIb/IIIa inhibitor. However, bivalirudin was associated with a 48% lower risk of major bleeding compared with unfractionated heparin plus GpIIb/IIIa inhibitor and 32% lower compared with unfractionated heparin alone.Conclusions In patients undergoing primary PCI, unfractionated heparin plus GpIIb/IIIa inhibitor and LMWH plus GpIIb/IIIa inhibitor were most efficacious, with the lowest rate of major adverse cardiovascular events, whereas bivalirudin was safest, with the lowest bleeding. These relationships should be considered in selecting anticoagulant therapies in patients undergoing primary PCI.</abstract><cop>England</cop><pub>British Medical Journal Publishing Group</pub><pmid>25389143</pmid><doi>10.1136/bmj.g6419</doi><edition>International edition</edition><oa>free_for_read</oa></addata></record> |
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| ispartof | BMJ (Online), 2014-11, Vol.349 (nov11 4), p.g6419-g6419 |
| issn | 0959-8138 1756-1833 0959-8146 1756-1833 |
| language | eng |
| recordid | cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_4227311 |
| source | MEDLINE; BMJ Journals - NESLi2; Applied Social Sciences Index & Abstracts (ASSIA); JSTOR Archive Collection A-Z Listing |
| subjects | Angioplasty Anticoagulants Anticoagulants - adverse effects Anticoagulants - therapeutic use Antithrombins - adverse effects Antithrombins - therapeutic use Bias Cardiology Estimates Heart attacks Hemorrhage - chemically induced Heparin - adverse effects Heparin - therapeutic use Heparin, Low-Molecular-Weight - adverse effects Heparin, Low-Molecular-Weight - therapeutic use Hirudins - adverse effects Humans Integrin beta3 Intervention Ischemia Meta-analysis Myocardial Infarction - therapy Peptide Fragments - adverse effects Peptide Fragments - therapeutic use Percutaneous Coronary Intervention Platelet Glycoprotein GPIIb-IIIa Complex - antagonists & inhibitors Polysaccharides - therapeutic use Purinergic P2Y Receptor Antagonists - therapeutic use Recombinant Proteins - adverse effects Recombinant Proteins - therapeutic use Stents - adverse effects Therapy Thrombosis - etiology Thrombosis - prevention & control Treatment Outcome |
| title | Anticoagulant therapy during primary percutaneous coronary intervention for acute myocardial infarction: a meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-11T04%3A36%3A01IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-jstor_pubme&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Anticoagulant%20therapy%20during%20primary%20percutaneous%20coronary%20intervention%20for%20acute%20myocardial%20infarction:%20a%20meta-analysis%20of%20randomized%20trials%20in%20the%20era%20of%20stents%20and%20P2Y12%20inhibitors&rft.jtitle=BMJ%20(Online)&rft.au=Bangalore,%20Sripal&rft.date=2014-11-11&rft.volume=349&rft.issue=nov11%204&rft.spage=g6419&rft.epage=g6419&rft.pages=g6419-g6419&rft.issn=0959-8138&rft.eissn=1756-1833&rft.coden=BMJOAE&rft_id=info:doi/10.1136/bmj.g6419&rft_dat=%3Cjstor_pubme%3E26518525%3C/jstor_pubme%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=1777792012&rft_id=info:pmid/25389143&rft_jstor_id=26518525&rfr_iscdi=true |