Spaulding C - AIMRADIAL 2013 - Heparin and radial

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Bleeding and anticoagulation : unfractionated heparin (UFH) is still the most cost effective

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Spaulding C - AIMRADIAL 2013 - Heparin and radial

  1. 1. Bleeding and Anticoagulation UFH is still the most cost effective Christian Spaulding, MD, FESC Cardiology Department Hôpital Européen Georges Pompidou, Paris Descartes University INSERM U 970, PARCC Paris, France
  2. 2. Conflicts of interest • Advisory board: Medtronic • Speaker’s bureau: Lilly, Iroko, Servier, Astra Zeneca, Cordis • Research grants from the French government on cardiac arrest
  3. 3. What are we trying to achieve? • We want to be cost effective • We don’t want the radial artery to occlude after a coronary angiogram: you may need it again for PCI • For PCI we want to avoid per and post-procedural complications such as stent thrombosis, and bleeding complications
  4. 4. Cost effectiveness • Prices in an University Hospital in Paris, France, (patient 70 kg): – UFH 5000 IU: 0,3 euros – LMWH 35 mg: 0,9 euros – Bivalirudin 250 mg: 408 euros Christian and Gilles ? Sunil and co?
  5. 5. What are we trying to achieve? • We want to be cost effective • We don’t want the radial artery to occlude after a coronary angiogram: you may need it again for PCI • For PCI we want to avoid per and post-procedural complications such as stent thrombosis, and bleeding complications
  6. 6. Heparin prevents radial artery occlusion, but: • What is the right dose? – UFH 50 IU/Kg or 5000 IU seem more effective 1 • Intra-arterial or systemic? – No difference 2 • Heparin is not the only factor for radial artery occlusion 3: – Radial artery size – Female gender, lower body weight – Sheath size – Numerous procedures through the same artery – Systolic blood pressure at hemostasis – Hemostasis technique Bernat I et al, Am J Cardiol 2011;107:1698–1701 2 Pancholy SB et al Am J Cardiol 2009;104:1083–1085 3 Hamon M et al EuroIntervention 2013;8:1242-1251 1
  7. 7. What are we trying to achieve? • We want to be cost effective • We don’t want the radial artery to occlude after a coronary angiogram • For PCI we want to avoid per and post-procedural complications such as stent thrombosis, and bleeding complications
  8. 8. Achieving a balance in prevention of ischemia and bleeding complications
  9. 9. Planned PCI: STEEPLE « The trial was not large enough to provide a definitive comparison of efficacy in the prevention of ischemic events » Montalescot G et al, N Engl J Med 2006;355:1006-17
  10. 10. ATOLL Trial design Randomization as early as possible (MICU +++) Real life population (shock, cardiac arrest included)  No anticoagulation and no lytic before Rx Similar antiplatelet therapy in both groups STEMI  Primary PCI ENOXAPARIN IV 0.5 mg/kg UFH IV IVRS with or without GPIIbIIIa 50-70 IU with GP IIbIIIa 70-100IU without GP IIbIIIa (Dose ACT-adjusted) Primary PCI UFH IV or SC ENOXAPARIN SC 30-day results Montalescot G et al, Lancet. 2011;378:693-703 
  11. 11. Bivalirudin reduced both ischemic and bleeding events in femoral-treated patients, no benefit in the radial-treated patients MacHaalany J et al, Am J Cardiol 2012;110:1742–1748
  12. 12. What are we trying to achieve? • We want to be cost effective • We don’t want the radial artery to occlude after a coronary angiogram: you may need it again for PCI • For PCI we want to avoid per and post-procedural complications such as stent thrombosis, and bleeding complications
  13. 13. How can we achieve these goals • Limited data on the use of anticoagulants in radial procedures • Coronary angiograms – 5000 IU UFH prevents radial occlusion • Planned PCI, STEMI or NSTEMI: what is the « firstline » anticoagulant? – UFH or LMWH ++ – Bivalirudin reduces bleeding complications however the benefit seems mitigated by the use of radial approach, there is no dedicated trial on bivalirudin + radial approach and cost is a serious limitation

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