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Anticoagulation for critically ill cardiac surgery patients: is primary bivalirudin the next step?
[heparin-induced thrombocytopenia]
Anticoagulation
with
unfractionated
heparin
(
UFH
)
in
critically
ill
cardiac
surgery
patients
has
several
limitations
,
including
the
risk
of
heparin-induced
thrombocytopenia
.
The
use
of
a
direct
thrombin
inhibitor
,
such
as
bivalirudin
,
might
either
treat
this
complication
or
completely
eliminate
it
.
The
aim
of
the
present
study
was
to
analyze
the
use
of
bivalirudin
in
this
setting
,
as
either
a
secondary
drug
switching
from
heparin
or
as
the
primary
anticoagulant
,
and
to
evaluate
clinical
outcomes
.
Propensity-matching
retrospective
analysis
.
A
cardiac
surgery
intensive
care
unit
.
One
hundred
propensity-matched
patients
who
received
heparin
or
bivalirudin
.
Bivalirudin
was
administered
as
a
first
-line
or
second
-line
drug
after
heparin
discontinuation
in
case
of
thrombocytopenia
and
suspicion
of
heparin-induced
thrombocytopenia
.
Twenty
-
six
patients
(
52
%
)
received
bivalirudin
as
a
primary
anticoagulant
,
while
24
patients
(
48
%
)
received
bivalirudin
after
switching
from
heparin
.
Bivalirudin
treatment
was
associated
with
a
reduction
of
major
bleeding
(
p
=
0
.
05
)
compared
with
the
control
group
.
Interestingly
,
in
an
intention-
to
-treat
analysis
,
patients
receiving
primary
bivalirudin
showed
significant
reductions
in
minor
bleeding
(
p
=
0
.
04
)
,
and
mortality
(
p
=
0
.
01
)
compared
with
the
secondary
bivalirudin
group
and
,
similarly
,
compared
with
the
rest
of
the
study
population
(
UFH
and
secondary
bivalirudin
patients
,
p
=
0
.
01
and
p
=
0
.
05
,
respectively
)
.
Predictors
of
hospital
mortality
by
multivariate
analysis
included
urgent
admission
(
odds
ratio
[
OR
]
=
2
.
7
;
95
confidence
interval
[
CI
]
,
1
.
03
-
7
.
2
;
p
=
0
.
04
)
,
;
septic
shock
(
OR
=
8
.
0
;
95
CI
,
2
.
26
-
28
.
7
;
p
<
0
.
005
)
and
primary
therapy
with
UFH
(
OR
=
19
.
2
;
95
CI
,
2
.
2
-
163
.
9
;
p
=
0
.
007
)
.
Novel
anticoagulant
strategies
might
play
a
crucial
role
in
critically
ill
cardiac
surgery
patients
.
In
a
propensity-matched
population
,
results
of
the
present
study
showed
that
primary
bivalirudin
anticoagulation
may
reduce
bleeding
complications
and
mortality
.
Diseases
Validation
Diseases presenting
"cardiac surgery"
symptom
acute rheumatic fever
dentinogenesis imperfecta
heparin-induced thrombocytopenia
holt-oram syndrome
homocystinuria without methylmalonic aciduria
thoracic outlet syndrome
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