Efficacy and safety of prehospital administration of unfractionated heparin, enoxaparin or bivalirudin in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: Insights from the ORBI registry.
BACKGROUND
Despite numerous studies in recent years, the best anticoagulant option for primary percutaneous coronary intervention (PCI) remains a matter of debate.


OBJECTIVE
To compare in-hospital outcomes after prehospital administration of low-dose unfractionated heparin (UFH)±glycoprotein IIb/IIIa inhibitors (GPIs), enoxaparin±GPIs, or bivalirudin in patients undergoing primary PCI for ST-segment elevation myocardial infarction (STEMI).


METHODS
A total of 1720 patients (median age 62.0 years, 79.2% male) who had been enrolled in a prospective registry and received an injectable anticoagulant in physician-staffed mobile intensive care units before primary PCI were included in the study. The main outcomes were in-hospital major adverse cardiovascular events (MACE) (a composite of all-cause mortality, non-fatal myocardial infarction, stroke or definite stent thrombosis) and in-hospital major bleeding (Bleeding academic research consortium type 3 or 5).


RESULTS
UFH was administered in 420 (24.4%) patients, enoxaparin in 1163 (67.6%) patients and bivalirudin in 137 patients (8.0%). Rates of in-hospital MACE were 7.4% with UFH, 6.0% with enoxaparin and 6.6% with bivalirudin, with no significant differences between groups (P=0.628). In-hospital major bleeding occurred in 1.7% of patients on UFH, 1.4% on enoxaparin and 1.5% on bivalirudin (P=0.851). By multivariable analysis, the prehospital anticoagulant used was not an independent predictor of MACE or major bleeding.


CONCLUSIONS
In this prospective registry, there were no significant differences in the rates of in-hospital MACE or major bleeding after prehospital initiation of UFH, enoxaparin or bivalirudin in patients treated by primary PCI for STEMI.
Service de cardiologie et maladies vasculaires, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France; Université de Rennes 1, LTSI, Rennes, France; Inserm, U1099, Rennes, France. Electronic address: vincent.auffret@chu-rennes.fr.
Vincent
V
Auffret
Service de cardiologie et maladies vasculaires, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France; Université de Rennes 1, LTSI, Rennes, France; Inserm, U1099, Rennes, France.
Guillaume
G
Leurent
Service de cardiologie et maladies vasculaires, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France; Université de Rennes 1, LTSI, Rennes, France; Inserm, U1099, Rennes, France.
Dominique
D
Boulmier
Service de cardiologie et maladies vasculaires, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France; Université de Rennes 1, LTSI, Rennes, France; Inserm, U1099, Rennes, France.
Marc
M
Bedossa
Service de cardiologie, centre hospitalier de Saint-Brieuc, Saint-Brieuc, France.
Amer
A
Zabalawi
Service de cardiologie, centre hospitalier de Lorient, Lorient, France.
Jean-Philippe
JP
Hacot
SAMU, centre hospitalier de Saint-Brieuc, Saint-Brieuc, France.
Isabelle
I
Coudert
Service de cardiologie, centre hospitalier de Vannes, Vannes, France.
Emmanuelle
E
Filippi
Département de cardiologie, CHU de Brest, Brest, France; EA4324, UFR sciences et techniques, optimisation des régulations physiologiques (ORPhy), Brest, France.
Philippe
P
Castellant
Service de cardiologie, centre hospitalier de Saint-Malo, Saint-Malo, France.
Antoine
A
Rialan
Service de cardiologie, centre hospitalier de Quimper, Quimper, France.
Gilles
G
Rouault
Service de cardiologie, clinique Saint-Laurent, Rennes, France.
Philippe
P
Druelles
SAMU, centre hospitalier de Vannes, Vannes, France.
Bertrand
B
Boulanger
SAMU, CHU de Brest, Brest, France.
Josiane
J
Treuil
Service des urgences médicales, CHU de Rennes, Rennes, France.
Bertrand
B
Avez
Service de cardiologie et maladies vasculaires, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France; Université de Rennes 1, LTSI, Rennes, France; Inserm, U1099, Rennes, France.
Marielle
M
Le Guellec
Département de cardiologie, CHU de Brest, Brest, France; EA4324, UFR sciences et techniques, optimisation des régulations physiologiques (ORPhy), Brest, France.
Martine
M
Gilard
Service de cardiologie et maladies vasculaires, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France; Université de Rennes 1, LTSI, Rennes, France; Inserm, U1099, Rennes, France.
Hervé
H
Le Breton
D000925:Anticoagulants / Q000008:administration & dosage; D000991:Antithrombins / Q000008:administration & dosage; D004562:Electrocardiography; D017984:Enoxaparin / Q000008:administration & dosage*; D005260:Female; D005500:Follow-Up Studies; D006493:Heparin / Q000008:administration & dosage*; D006629:Hirudins / Q000008:administration & dosage*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010446:Peptide Fragments / Q000008:administration & dosage*; D062645:Percutaneous Coronary Intervention; D011300:Preoperative Care / Q000379:methods*; D011446:Prospective Studies; D011994:Recombinant Proteins / Q000008:administration & dosage; D012042:Registries; D000072657:ST Elevation Myocardial Infarction / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome
D000925:Anticoagulants; D000991:Antithrombins; D017984:Enoxaparin; D006629:Hirudins; D010446:Peptide Fragments; D011994:Recombinant Proteins; D006493:Heparin; C074619:bivalirudin
Bivalirudin; Bivalirudine; Enoxaparin; Enoxaparine; Héparine non fractionnée; Outcomes; Pronostic; ST-segment elevation myocardial infarction; Syndrome coronaire aigu avec élévation du segment ST; Unfractionated heparin