Prasugrel Plus Bivalirudin vs Clopidogrel Plus Heparin STEMI
Prasugrel Plus Bivalirudin vs Clopidogrel Plus Heparin STEMI
Early mechanical reperfusion by primary percutaneous coronary intervention (PCI) is the standard treatment strategy for patients with ST-segment elevation myocardial infarction (STEMI). Adjunct antithrombotic therapy with antiplatelet and anticoagulant agents is the prerequisite for the safe and effective performance of primary PCI. Bivalirudin and prasugrel have both shown significant benefits vs. conventional therapy in two separate studies. In the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial, the direct thrombin inhibitor bivalirudin after pre-treatment with clopidogrel resulted in improved net clinical outcome compared with heparin plus glycoprotein (GP) IIb/IIIa inhibitors in STEMI patients undergoing primary PCI. This reduction was driven by a lower rate of major bleeding. However, during the first 24 h after PCI there was an increase in stent thrombosis rates with bivalirudin. In the TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet inhibitioN with prasugrel–Thrombolysis In Myocardial Infarction (TRITON-TIMI) 38 trial, the third-generation thienopyridine prasugrel was superior to clopidogrel in patients with acute coronary syndrome with or without ST-segment elevation regarding the composite of death, myocardial infarction, or stroke. Both prasugrel and bivalirudin have received a class I recommendation for their use in STEMI patients. However, so far no specifically designed studies have prospectively assessed the potential advantages of the combination of prasugrel plus bivalirudin with that of clopidogrel plus heparin. Theoretically, both drugs may have synergistic effects on ischaemic and bleeding complications that maximize patients' clinical outcomes. The Bavarian Reperfusion Alternatives Evaluation (BRAVE) 4 study aimed at assessing the hypothesis that in STEMI patients with planned primary PCI a strategy based on prasugrel plus bivalirudin is superior to a strategy based on clopidogrel plus unfractionated heparin in terms of net clinical outcomes.
Background
Early mechanical reperfusion by primary percutaneous coronary intervention (PCI) is the standard treatment strategy for patients with ST-segment elevation myocardial infarction (STEMI). Adjunct antithrombotic therapy with antiplatelet and anticoagulant agents is the prerequisite for the safe and effective performance of primary PCI. Bivalirudin and prasugrel have both shown significant benefits vs. conventional therapy in two separate studies. In the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial, the direct thrombin inhibitor bivalirudin after pre-treatment with clopidogrel resulted in improved net clinical outcome compared with heparin plus glycoprotein (GP) IIb/IIIa inhibitors in STEMI patients undergoing primary PCI. This reduction was driven by a lower rate of major bleeding. However, during the first 24 h after PCI there was an increase in stent thrombosis rates with bivalirudin. In the TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet inhibitioN with prasugrel–Thrombolysis In Myocardial Infarction (TRITON-TIMI) 38 trial, the third-generation thienopyridine prasugrel was superior to clopidogrel in patients with acute coronary syndrome with or without ST-segment elevation regarding the composite of death, myocardial infarction, or stroke. Both prasugrel and bivalirudin have received a class I recommendation for their use in STEMI patients. However, so far no specifically designed studies have prospectively assessed the potential advantages of the combination of prasugrel plus bivalirudin with that of clopidogrel plus heparin. Theoretically, both drugs may have synergistic effects on ischaemic and bleeding complications that maximize patients' clinical outcomes. The Bavarian Reperfusion Alternatives Evaluation (BRAVE) 4 study aimed at assessing the hypothesis that in STEMI patients with planned primary PCI a strategy based on prasugrel plus bivalirudin is superior to a strategy based on clopidogrel plus unfractionated heparin in terms of net clinical outcomes.
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