In-hospital outcomes after switching from a bivalirudin-first strategy to an unfractionated heparin-first strategy for percutaneous coronary interventions.

BACKGROUND: The optimal anticoagulation strategy for percutaneous coronary interventions (PCIs) remains debated. We report outcomes after switching from a bivalirudin-first to an unfractionated heparin (UFH)-first strategy for PCIs in a large academic center.
METHODS: Patients undergoing PCI from June 1st 2013-May 31st, 2015 were identified through the National Cardiovascular Data Registry (NCDR), and divided into the "bivalirudin era" (June 2013-July 2014) and the "UFH era" (October 2014-May 2015). Bleeding outcomes were compared using multivariable logistic regression adjusted for potential confounders.
RESULTS: A total of 1,145 patients were identified (bivalirudin era =752, UFH era =393). Radial access for PCI increased over time, and was lower in the bivalirudin era (26% vs. 34%, P<0.05). There were 32 major bleeds (4.3%) in the bivalirudin era and 29 major bleeds (7.4%) in the UFH era (P=0.03), with the majority being hemoglobin drops (≥3 g/dL) without overt clinical bleeding (85.7% of bleeds in the bivalirudin era and 86.2% of bleeds in the UFH era). After adjustments for other common major causes of bleeding, bivalirudin was associated with 78% lower odds of bleeding (OR =0.22; 95% CI: 0.05-0.91).
CONCLUSIONS: An increase in major bleeding events occurred after switching to an UFH-first strategy, primarily associated with hemoglobin drop (≥3 g/dL) without overt clinical bleeding. Major overt bleeding was rare (0.3%) and similar in both groups. These results suggest a UFH-first strategy for PCI may have a role in patients with low bleeding risk.