title: Bivalirudin versus heparin in non-ST and ST-segment elevation myocardial infarction-a registry-based randomized clinical trial in the SWEDEHEART registry (the VALIDATE-SWEDEHEART trial).
abstract: BACKGROUND
  The optimal anticoagulant for patients with acute coronary syndrome treated with percutaneous coronary intervention (PCI) has not been validated in current practice of radial approach and pretreatment with potent P2Y12 inhibitors. Several studies have indicated increased bleeding rate and, in some instances, even increased mortality by the routine use of heparin and glycoprotein IIb/IIIa inhibitors compared to bivalirudin. Direct comparison of bivalirudin versus heparin alone has yielded contradictory results depending on study designs.
  
  
  METHODS
  The VALIDATE-SWEDEHEART trial is a multicenter, prospective, randomized, registry-based, controlled, and open-label clinical trial in patients with ST-segment elevation myocardial infarction (STEMI) or non-STEMI undergoing PCI pretreated with ticagrelor, prasugrel, or cangrelor. We hypothesize that bivalirudin is superior to heparin alone in reducing death, myocardial infarction, and major bleeding events at 180 days (primary end point). The trial will enroll 3,000 patients with STEMI and 3,000 patients with non-STEMI undergoing PCI. The trial will use a hybrid registry-based randomized clinical trial design where inclusion, randomization, and baseline data collection are performed using The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry. The primary composite end point (death, myocardial infarction, or major bleeding events at 180 days) will be identified through active screening after 7 and 180 days and adjudicated by a blinded central end point committee. Secondary end points and long-term outcomes will be recorded from national registries.
  
  
  CONCLUSIONS
  The VALIDATE-SWEDEHEART trial is founded on a nationwide clinical registry and uses a hybrid registry-based randomized clinical trial (RRCT) design methodology to evaluate efficacy and safety of bivalirudin as compared to heparin alone for acute coronary syndrome, in a large population receiving contemporary recommended therapies including predominantly radial invasive approach and pretreatment with potent P2Y12 inhibitors.
authors.affiliation: Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden. Electronic address: david.erlinge@med.lu.se.
authors.forename: David
authors.initials: D
authors.lastname: Erlinge
authors.affiliation: Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden.
authors.forename: Sasha
authors.initials: S
authors.lastname: Koul
authors.affiliation: Department of Cardiology, Umeå University, Umeå, Sweden.
authors.forename: Peter
authors.initials: P
authors.lastname: Eriksson
authors.affiliation: Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden.
authors.forename: Fredrik
authors.initials: F
authors.lastname: Scherstén
authors.affiliation: Department of Cardiology, Sahlgrenska University, Gothenburg, Sweden.
authors.forename: Elmir
authors.initials: E
authors.lastname: Omerovic
authors.affiliation: Department of Cardiology, Danderyd, Karolinska University, Stockholm, Sweden.
authors.forename: Rikard
authors.initials: R
authors.lastname: Linder
authors.affiliation: Department of Medical Sciences, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
authors.forename: Olof Petter
authors.initials: OP
authors.lastname: Östlund
authors.affiliation: Department of Medical Sciences, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
authors.forename: Lars
authors.initials: L
authors.lastname: Wallentin
authors.affiliation: Department of Cardiology, Faculty of Health, Örebro University, Sweden.
authors.forename: Ole
authors.initials: O
authors.lastname: Fröbert
authors.affiliation: Department of Medical Sciences, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
authors.forename: Stefan
authors.initials: S
authors.lastname: James
mesh_terms: D061605:Administration, Intravenous; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects; D003131:Combined Modality Therapy; D004305:Dose-Response Relationship, Drug; D064420:Drug-Related Side Effects and Adverse Reactions / Q000209:etiology / Q000517:prevention & control; D004562:Electrocardiography / Q000379:methods; D005260:Female; D006493:Heparin / Q000008:administration & dosage / Q000009:adverse effects; D006629:Hirudins / Q000008:administration & dosage / Q000009:adverse effects; D006801:Humans; D008297:Male; D008875:Middle Aged; D000072658:Non-ST Elevated Myocardial Infarction / Q000175:diagnosis / Q000188:drug therapy; D010043:Outcome and Process Assessment, Health Care; D010446:Peptide Fragments / Q000008:administration & dosage / Q000009:adverse effects; D062645:Percutaneous Coronary Intervention / Q000379:methods; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000009:adverse effects; D012042:Registries; D000072657:ST Elevation Myocardial Infarction / Q000175:diagnosis / Q000188:drug therapy; 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