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

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

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

9. Achieving a balance in prevention of
ischemia and bleeding complications

11. 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

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

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