Bivalirudin or Heparin in Patients Undergoing Invasive Management of Acute Coronary Syndromes

Giuseppe Gargiulo, Greta Carrara, Enrico Frigoli, Pascal Vranckx, Sergio Leonardi, Nestor Ciociano, Gianluca Campo, Ferdinando Varbella, Paolo Calabro, Stefano Garducci, Alessandro Iannone, Carlo Briguori, Giuseppe Ando, Gabriele Crimi, Ugo Limbruno, Roberto Garbo, Paolo Sganzerla, Filippo Russo, Alessandro Lupi, Bernardo CorteseArturo Ausiello, Salvatore Ierna, Giovanni Esposito, Dennis Zavalloni, Andrea Santarelli, Gennaro Sardella, Simone Tresoldi, Nicoletta de Cesare, Alessandro Sciahbasi, Antonio Zingarelli, Paolo Tosi, Arnoud van't Hof, Elmir Omerovic, Salvatore Brugaletta, Stephan Windecker, Marco Valgimigli*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


BACKGROUND Contrasting evidence exists on the comparative efficacy and safety of bivalirudin and unfractionated heparin (UFH) in relation to the planned use of glycoprotein IIb/IIIa inhibitors (GPIs). OBJECTIVES This study assessed the efficacy and safety of bivalirudin compared with UFH with or without GPIs in patients with acute coronary syndrome (ACS) who underwent invasive management. METHODS In the MATRIX (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX) program, 7,213 patients were randomly assigned to receive either bivalirudin or UFH with or without GPIs at discretion of the operator. The 30-day coprimary outcomes were major adverse cardiovascular events (MACEs) (a composite of death, myocardial infarction, or stroke), and net adverse clinical events (NACEs) (a composite of MACEs or major bleeding). RESULTS Among 3,603 patients assigned to receive UFH, 781 (21.7%) underwent planned treatment with GPI before coronary intervention. Bailout use of GPIs was similar between the bivalirudin and UFH groups (4.5% and 5.4%) (p = 0.11). At 30 days, the 2 coprimary endpoints of MACEs and NACEs, as well as individual endpoints of mortality, myocardial infarction, stent thrombosis or stroke did not differ among the 3 groups after adjustment. Compared with the UFH and UFH+GPI groups, bivalirudin reduced bleeding, mainly the most severe bleeds, including fatal and nonaccess site-related events, as well as transfusion rates and the need for surgical access site repair. These findings were not influenced by the administered intraprocedural dose of UFH and were confirmed at multiple sensitivity analyses, including the randomly allocated access site. CONCLUSIONS In patients with ACS, the rates of MACEs and NACEs were not significantly lower with bivalirudin than with UFH, irrespective of planned GPI use. However, bivalirudin significantly reduced bleeding complications, mainly those not related to access site, irrespective of planned use of GPIs. (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX [MATRIX]; NCT01433627) (c) 2018 by the American College of Cardiology Foundation.
Original languageEnglish
Pages (from-to)1231-1242
Number of pages12
JournalJournal of the American College of Cardiology
Issue number11
Publication statusPublished - 20 Mar 2018


  • acute coronary syndrome
  • bivalirudin
  • GP IIb/IIIa inhibitor
  • heparin

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