Centurión Osmar Antonio
From the Department of Cardiology, Clínic Hospital, Asunción National University, Asunción, Paraguay; and Cardiovascular Institute, Sanatorio Migone-Battilana, Asunción, Paraguay.
Crit Pathw Cardiol. 2015 Jun;14(2):62-6. doi: 10.1097/HPC.0000000000000043.
The results of randomized trials and observational studies make a strong argument for the use of bivalirudin rather than heparin plus systematic glycoprotein (GP) IIb/IIIa inhibitors for the great majority of patients undergoing percutaneous coronary interventions (PCI). However, there is no doubt that the benefit observed with bivalirudin was achieved because of the major bleeding complications with heparin plus GP IIb/IIIa inhibitors. Therefore, if we diminish bleeding complications by eliminating the systematic utilization of GP IIb/IIIa inhibitors, there would be a lesser benefit with the use of bivalirudin. When this latter drug was compared with unfractionated heparin alone there was no benefit in ischemic complications but a decrease in major bleeding complications with bivalirudin. However, a very recent meta-analysis shed more insights on the utilization of bivalirudin versus heparin regimens during PCI. Findings from this meta-analysis suggest that routine use of bivalirudin offers little advantage over heparin among PCI patients. In a detailed analysis of some randomized trials and observational studies with bivalirudin in non-ST-segment elevation acute coronary syndrome patients done by myself and published almost 4 years ago in this journal, I rendered some reflections on the future widespread use of bivalirudin. "In the setting of PCI and in the absence of GP IIb/IIIa inhibitors, bivalirudin did not offer any beneficial effect in the incidence of the composite end points when compared with heparin. For now, in real world practice, one would probably choose a well-known cheaper drug that has already passed the test of time, heparin. There may be reinforcement in the sole utilization of heparin confining GP IIb/IIIa inhibitors and other intravenous antithrombotics to bailout therapy for periprocedural PCI complications in acute coronary syndrome patients." Therefore, is it the beginning of a new era with bivalirudin or is it a welcome back to an old friend, heparin? Indeed, after more than two decades, it is always good to welcome back an old friend, unfractionated heparin.
随机试验和观察性研究的结果有力地支持，对于绝大多数接受经皮冠状动脉介入治疗（PCI）的患者，使用比伐卢定而非肝素加系统性糖蛋白（GP）IIb/IIIa抑制剂。然而，毫无疑问，观察到比伐卢定的益处是因为肝素加GP IIb/IIIa抑制剂存在严重出血并发症。因此，如果我们通过消除系统性使用GP IIb/IIIa抑制剂来减少出血并发症，那么使用比伐卢定的益处就会减少。当将后一种药物与单纯普通肝素比较时，比伐卢定在缺血并发症方面没有益处，但主要出血并发症有所减少。然而，最近的一项荟萃分析对PCI期间比伐卢定与肝素方案的使用有了更多见解。该荟萃分析的结果表明，在PCI患者中，常规使用比伐卢定相比肝素几乎没有优势。在大约4年前我本人在本杂志发表的一项对非ST段抬高急性冠状动脉综合征患者使用比伐卢定的一些随机试验和观察性研究的详细分析中里，我对比伐卢定未来的广泛使用进行了一些思考。“在PCI情况下且没有GP IIb/IIIa抑制剂时，与肝素相比，比伐卢定在复合终点发生率方面没有任何有益效果。目前，在现实世界实践中，人们可能会选择一种经过时间考验的知名且更便宜的药物，即肝素。在急性冠状动脉综合征患者中，可能会加强单纯使用肝素，将GP IIb/IIIa抑制剂和其他静脉内抗栓药物限制用于PCI围手术期并发症的补救治疗。”那么，这是比伐卢定新时代的开始，还是对老朋友肝素的回归呢？的确，二十多年后，欢迎老朋友普通肝素回归总是好事。
