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Choosing the right anti-coagulant (AC) during percutaneous coronary intervention (PCI) for the right patient that balances the bleeding risk with ischemic efficacy is an ongoing challenge. We did a network meta-analysis to compare the currently used ACs for PCI.
We searched PubMed, The Cochrane Library, and relevant meeting abstracts for randomized trials that compared unfractionated heparin (UFH), bivalirudin, and low molecular weight heparin (LMWH) with or without glycoprotein IIb/IIIa inhibitor (GPI) for PCI. Endpoints (up to 30-day) included were: major bleeding (MB), death, major adverse cardiac events (MACE), and stent thrombosis (ST).
We analyzed 74 trials (n = 73,760) allocated to 6 AC combinations (Figure 1A). Compared to UFH, UFH+GPI, bivalirudin, LMWH, and LMWH+GPI were associated with lower MACE (Figure 1B). The hierarchy for MACE (highest to lowest) was LMWH+GPI, UFH+GPI, bivalirudin+GPI, LMWH, Bivalirudin and UFH. While there was no statistical difference between ACs for death, LMWH was ranked the highest and UFH the lowest (SUCRA values 72% and 28% respectively). Bivalirudin was the safest AC (Figure 1C and 1D), and was associated with lower MB compared to UFH+GPI (odds ratio (OR) 0.54, 95% confidence interval (CI) 0.42-0.68) and UFH (OR 0.68, CI 0.51-0.90). However, ST was higher with bivalirudin compared to UFH+GPI (OR 1.72, CI 1.10-2.67).
LMWH+GPI and UFH+GPI are the most effective and bivalirudin the safest AC for PCI. AC selection maybe tailored to patient’s risk profile.