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Spaulding C - AIMRADIAL 2013 - Heparin and radial
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. 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. 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. 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. 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.
7. 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
8. 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
12. 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
13.
14.
15.
16. 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
17. 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
18. 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