title: The comparative efficacy of bivalirudin is markedly attenuated by use of radial access: insights from Blue Cross Blue Shield of Michigan Cardiovascular Consortium.
abstract: The purpose of our study was to evaluate the relative impact of bivalirudin on bleeding outcomes associated with trans-radial interventions (TRI) in real world practice.
  
  
  
  Data for patients undergoing percutaneous coronary intervention (PCI) between January 2010 and March 2014 at the 47 hospitals participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) were utilized. Propensity matching was used within cohorts defined by access site. The impact of bivalirudin use on in-hospital outcomes was evaluated with Fisher's exact tests. Among patients undergoing trans-femoral interventions (TFI), use of bivalirudin was associated with a reduction in bleeding compared with both glycoprotein IIb/IIIa inhibitors (GPI; 1.67 vs. 3.46%, absolute risk reduction (ARR) 1.79%, odds ratio, OR, 0.47, confidence interval, CI, 0.41-0.54, number needed to treat, NNT 56, P < 0.001) and heparin (1.26 vs. 1.76%, ARR 0.5%, OR 0.71, CI 0.61-0.82, NNT 197, P < 0.001). Among patients undergoing TRI, there was a more modest absolute reduction in bleeding with bivalirudin compared with GPI (0.79 vs. 1.41%, ARR 0.62%, OR 0.56, CI 0.34-0.90, NNT 161, P = 0.016) and no difference in bleeding compared with heparin (0.46 vs. 0.46%, OR 1, CI 0.54-1.84, P = 1).
  
  
  
  Bivalirudin is markedly efficacious in reducing bleeding in patients undergoing TFI. The reduction in bleeding associated with bivalirudin use is minimal to absent in patients undergoing TRI. Given its lower cost and comparable outcomes, heparin should be the preferred anticoagulation strategy in those undergoing radial PCI.
authors.affiliation: Division of Cardiovascular Medicine, University of Michigan Health System, 2A394, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5853, USA.
authors.forename: Emily
authors.initials: E
authors.lastname: Perdoncin
authors.affiliation: Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
authors.forename: Milan
authors.initials: M
authors.lastname: Seth
authors.affiliation: Division of Cardiovascular Medicine, Beaumont Health System, Royal Oak, MI, USA.
authors.forename: Simon
authors.initials: S
authors.lastname: Dixon
authors.affiliation: Cardiac and Vascular Research Center of Northern Michigan, Petoskey, MI, USA.
authors.forename: Louis
authors.initials: L
authors.lastname: Cannon
authors.affiliation: Outpatient Cardiovascular Services, Henry Ford Hospital, Detroit, MI, USA.
authors.forename: Akshay
authors.initials: A
authors.lastname: Khandelwal
authors.affiliation: Division of Cardiovascular Medicine, Oakwood Hospital, Dearborn, MI, USA.
authors.forename: Arthur
authors.initials: A
authors.lastname: Riba
authors.affiliation: Division of Cardiovascular Medicine, St. John Providence Hospital, Detroit, MI, USA.
authors.forename: Shukri
authors.initials: S
authors.lastname: David
authors.affiliation: Division of Cardiovascular Medicine, Spectrum Health, Grand Rapids, MI, USA.
authors.forename: David
authors.initials: D
authors.lastname: Wohns
authors.affiliation: Division of Cardiovascular Medicine, University of Michigan Health System and Veteran Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA hgurm@med.umich.edu.
authors.forename: Hitinder
authors.initials: H
authors.lastname: Gurm
mesh_terms: D000925:Anticoagulants; D054598:Blue Cross Blue Shield Insurance Plans; D006493:Heparin; D006629:Hirudins; D006801:Humans; D008824:Michigan; D010446:Peptide Fragments / Q000627:therapeutic use*; D062645:Percutaneous Coronary Intervention; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D011994:Recombinant Proteins / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D006629:Hirudins; D010446:Peptide Fragments; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D011994:Recombinant Proteins; D006493:Heparin; C074619:bivalirudin
keywords: Bivalirudin; Bleeding; Radial access