Pinto Duane S, Ogbonnaya Augustina, Sherman Steven A, Tung Patricia, Normand Sharon-Lise T
Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02115, USA.
Circ Cardiovasc Qual Outcomes. 2012 Jan;5(1):52-61. doi: 10.1161/CIRCOUTCOMES.111.961938. Epub 2012 Jan 10.
Randomized trials show improved outcomes among acute coronary syndrome patients treated with bivalirudin. The objective of this analysis was to compare clinical and economic outcomes in ST-elevation myocardial infarction (STEMI) patients encountered in routine clinical practice undergoing primary percutaneous coronary intervention (PPCI), treated with bivalirudin or heparin+GP IIb/IIIa receptor inhibitor (heparin+GPI).
STEMI admissions from January 1, 2004 through March 31, 2008 among patients receiving PPCI and bivalirudin or heparin+GPI in the Premier hospital database were identified. The probability of receiving bivalirudin was estimated using individual and hospital variables; using propensity scores, each bivalirudin patient was matched to 3 heparin+GPI treated patients. The primary outcome was in-hospital death. Rates of bleeding, transfusion, length of stay, and in-hospital cost were secondary outcomes. There were 59,917 STEMI PPCIs receiving bivalirudin (n=6735) or heparin+GPI (n=53,182). Seventy-nine percent of bivalirudin patients matched, resulting in 21,316 STEMI PPCIs for analysis. Compared with heparin+GPI patients, bivalirudin patients had fewer deaths (3.2% versus 4.0%; P=0.011) and less inpatient bleeding (clinically apparent bleeding [6.9% versus 10.5%, P<0.0001], clinically apparent bleeding with transfusion [1.6% versus 3.0%, P<0.0001], and transfusion [5.9% versus 7.6%, P<0.0001]). Patients receiving bivalirudin had shorter average length of stay (mean 4.3 versus 4.5 days; P<0.0001), with lower in-hospital cost (mean $18,640 versus $19,967 [median $14,462 versus $16,003], P<0.0001).
This large "real-world" retrospective analysis demonstrates that bivalirudin therapy compared with heparin+GPI is associated with a lower rate of inpatient death, inpatient bleeding, and decreased overall in-hospital cost in STEMI patients undergoing PPCI.
随机试验表明，接受比伐卢定治疗的急性冠状动脉综合征患者预后有所改善。本分析的目的是比较在常规临床实践中接受直接经皮冠状动脉介入治疗（PPCI）的ST段抬高型心肌梗死（STEMI）患者，使用比伐卢定或肝素加糖蛋白IIb/IIIa受体抑制剂（肝素+GPI）治疗后的临床和经济结局。
在Premier医院数据库中，识别出2004年1月1日至2008年3月31日期间接受PPCI且使用比伐卢定或肝素+GPI治疗的STEMI入院患者。使用个体和医院变量估计接受比伐卢定治疗的概率；利用倾向评分，将每位接受比伐卢定治疗的患者与3位接受肝素+GPI治疗的患者进行匹配。主要结局是住院死亡。出血、输血、住院时间和住院费用是次要结局。共有59,917例STEMI患者接受了比伐卢定（n = 6735）或肝素+GPI（n = 53,182）治疗。79%的比伐卢定治疗患者成功匹配，最终纳入21,316例STEMI患者进行分析。与肝素+GPI治疗患者相比，接受比伐卢定治疗的患者死亡人数更少（3.2%对4.0%；P = 0.011），住院期间出血更少（临床明显出血[6.9%对10.5%，P < 0.0001]，伴有输血的临床明显出血[1.6%对3.0%，P < 0.0001]，以及输血[5.9%对7.6%，P < 0.0001]）。接受比伐卢定治疗的患者平均住院时间更短（平均4.3天对4.5天；P < 0.0001），住院费用更低（平均18,640美元对19,967美元[中位数14,462美元对16,003美元]，P < 0.0001）。
这项大型“真实世界”回顾性分析表明，与肝素+GPI相比，比伐卢定治疗与接受PPCI的STEMI患者住院死亡率更低、住院出血率更低以及住院总费用降低相关。
