Author + information
- Akshay Mishra, MBBS, MD, DnB⁎ ( and )
- Darren Walters, MBBS, MPhil, FRACP, FCSANZ, FSCAI
- ↵⁎Department of Cardiology, The Prince Charles Hospital, Rode Rd. Brisbane, Queensland 4032, Australia
White et al. (1) present an interesting case for the ability to switch to bivalirudin therapy from heparin (unfractionated heparin or enoxaparin) in non–ST-segment elevation acute coronary syndrome. The baseline characteristics of the 2 groups (consistent vs. switched), however, show a statistically greater proportion of high-risk patients in the consistent treatment group (see Table 1 of White et al. ). Thus, similarity of the 2 groups is not a strength of the study as suggested.
Removal of the bivalirudin plus glycoprotein (GP) IIb/IIIa group from this post-hoc analysis effectively removes a large population that could have increased bleeding complications, and it would be interesting to see whether the end points could be maintained if the switch from heparin to bivalirudin plus GP IIb/IIIa inhibitors was added to the population studied.
Bivalirudin was compared with heparin plus a GP IIb/IIIa inhibitor. Although recommended by guidelines, in the setting described, the proportion of patients being placed on GP IIb/IIIa inhibitors in real-world practice is much lower (i.e., approximately 25% in the U.S.  and 5% in Australia ).
Although one could expect some mortality benefit in the switched group, because of reduced bleeding over a length of time as in the ISAR (Innovative Stratification of Arrhythmic Risk) trials (4), the cost effectiveness of bivalirudin is a critical question when considering popular use.
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