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Ask Procured Health: What evidence supports using heparin for PCI rather than bivalirudin?

In talking to healthcare leaders about drug utilization, I’ve fielded many questions concerning the application of clinical evidence to specific drugs and drug categories. I address one popular topic below.

DEAR PROCURED HEALTH: Heparin is much less expensive than bivalirudin. What evidence can I use to support standardizing to it as our primary anticoagulant for percutaneous coronary intervention (PCI)? – HOPING FOR HEPARIN

DEAR HOPING FOR HEPARIN:
For health systems that have not yet set policies on appropriate use of heparin vs. bivalirudin for PCI, some compelling new evidence makes now the perfect time to start the conversation with your physicians.

In particular, exciting results from a recent trial show that heparin and bivalirudin have similar efficacy and safety outcomes.1 A few details to note:

  • The study is robust in terms of design and number of patients. The randomized controlled trial included ~6,000 patients with acute coronary syndromes in Sweden.
  • Glycoprotein IIb/IIIa inhibitors were administered to less than 3% of patients in each group. Consistent with evidence that routine GPI use contributes to higher bleeding risk2 without improving outcomes,3,4 only emergent, unplanned use was included.
  • A radial-artery approach was used in ~90% of patients. While this is typical in some parts of Europe and Asia, current adoption of radial access is estimated to be ~30% in the US.5
  • ~95% of patients were also treated with high-potency dual antiplatelet therapy. Organizations standardizing to heparin should also consider concurrent use of a high-potency P2Y12 such as prasugrel or ticagrelor.

There was no statistically significant difference between heparin and bivalirudin as measured by outcomes of death, myocardial infarction, or bleeding at 30 and 180 days, including in patients with comorbidities such as diabetes or renal failure. Knowing that the lack of difference could be related to the above factors, hospitals should take a look at their overall PCI practice when considering standardization to heparin.

Procured Health’s online Pharmacy solution applies the power of evidence to help health systems optimize costs and improve patient care. To learn more, email [email protected].

This Article is provided "AS IS", with all faults and without any warranty of any kind; any and all warranties are expressly disclaimed. No information in this Article is, or should be construed as medical advice, a guarantee of any product safety or any endorsement of any product or service; use of this Article is at your own risk. Procured shall not be liable, in any way, for any use of this Article or decisions made and/or actions taken based upon the contents herein. Discussion of experimental uses of drugs as described in this Article is for informational purposes only, and is not to be interpreted as an endorsement or encouragement of off-label use of any product.

1 "Bivalirudin Versus Heparin Monotherapy in Myocardial Infarction." Erlinge D, Omerovic E, Fröbert O, Linder R, et al, The New England Journal of Medicine, (9/2017)

"An updated comprehensive meta-analysis of bivalirudin vs heparin use in parimary percutanous coronary intervention." Shah R, Rogers KC, Matin K et al, American Heart Journal, (5/2016)

3 "Early versus delayed, provisional eptifibatide in acute coronary syndromes." Giugliano RP, White JA, Bode C, et al.The New England Journal of Medicine, (1/2009)

4  "Routine upstream initiation vs deferred selective use of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: the ACUITY Timing trial." Stone GW, Bertrand ME, Moses JW, et al. JAMA, (2/2007)

5 "Radial access adoption in the United States"
https://www.dicardiology.com/article/radial-access-adoption-united-states

Topics: Pharmacy, Ask Procured Health

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