Bivalirudin vs Heparin in NSTEMI and STEMI in Patients on Modern Antiplatelet Therapy in SWEDEHEART

Study Overview
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Brief Summary
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In this trial we test the hypothesis that PCI and bivalirudin is superior to heparin alone (according to local protocol) in reducing death, MI, and major bleeding in patients with NSTEMI or STEMI at 180 days (primary end point), treated with ticagrelor or prasugrel.

Detailed Description
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The follow up of endpoints will be performed using SWEDEHEART and national registries. Follow up of primary endpoints and stroke will also be performed by telephone contacts with the patients or first degree relatives by a nurse phone call after 7 days and 180 days. The nurses will also accumulate hospital record information on these endpoints. A central adjudication will be performed for all reported primary endpoints for the first 180 days follow up. Every site will prepare source documents for the event and send it to UCR for central adjudication by an independent committee.

Official Title
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Bivalirudin vs Heparin in NSTEMI and STEMI in Patients on Modern Antiplatelet Therapy in SWEDEHEART A Multicenter, Prospective, Randomized Controlled Clinical Trial Based on the SWEDEHEART Platform

Conditions
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ST-segment Elevation Myocardial Infarction, Non ST-segment Elevation Myocardial Infarction

Intervention / Treatment
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* Drug: bivalirudin
* Drug: Heparin


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients with a diagnosis of NSTEMI as judged by the physician in accordance with current guideline definitions (positive troponin) or, patients with a diagnosis of STEMI as defined by chest pain suggestive for myocardial ischemia for at least 30 minutes before hospital admission, time from onset of symptoms of less than 24 hours, and an ECG with new ST-segment elevation in two or more contiguous leads of ≥0.2 mV in leads V2-V3 and/or ≥0.1 mV in other leads or a probable new-onset left bundle branch block. PCI of culprit lesion is intended (therapeutic PCI, not primarily diagnostic PCI). Treated with bolus dose of ticagrelor or prasugrel before start of PCI. See 2.6 Ability to provide informed consent Age 18 years or older Exclusion Criteria: Previous randomization in the VALIDATE-SWEDEHEART trial. Known terminal disease with life expectancy less than one year. Patients with known ongoing bleeding Patients with uncontrolled hypertension in the opinion of the investigator Patients with known subacute bacterial endocarditis Patients with known severe renal (GFR < 30 ml/min) and/or liver dysfunction Patients with known thrombocytopenia or thrombocyte function defects Any other contraindication for the study medications. Heparin > 5000U Before arriving to PCI lab or > 3000 U given during angiography before randomization. GpIIb/IIIa inhibitors have been given or are pre-planned to be given during the procedure.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: bivalirudin<br>bivalirudin as intravenous bolus of 0,75 mg per kilogram followed by an infusion of 1,75 mg per kilogram per hour | Drug: bivalirudin<br>* Will be administered as an intravenous bolus of 0.75 mg per kilogram, followed by an infusion of 1.75 mg per kilogram per hour). Bivalirudin will be administered alone or with a low dose of heparin up to 3000U heparin in lab or up to 5000 U given pre-hospital according to local practice.<br>* Other names: Angiox;|
| Active Comparator: heparin<br>unfractionated Heparin 5 000 IU/ml as intravenous bolus according to local practice | Drug: Heparin<br>* Treatment with unfractionated Heparin 5000 IU/ml i.v. ,Leo Pharma, Sweden, (the control group). Heparin in the control group is administered as an intravenous or intra-arterial bolus according to local practice. A dose of 70-100 U/kg is recommended<br>* Other names: Heparin 5000 IU/ml i.v. ,Leo Pharma;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Death, Myocardial infarction and major bleeding event |  | 180 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Death, Myocardial infarction and major bleeding events in the subgroups NSTEMI and STEMI |  | 180 days | 
| Time to primary endpoints (death, myocardial infarction and major bleeding event) | Time to individual components of the primary end point (death, myocardial infarction and major bleeding). | 180 days | 
| Number of events where primary endpoints (death, myocardial infarction and major bleeding event) and stroke have been registered | The primary end point combined with stroke as reported in the Swedish national patient registry. | 180 days | 
| Number of events where primary endpoints (death, myocardial infarction and major bleeding event) have been registered in heparin subgroups (U/kg, groups with certain max ACT values etc) |  | 180 days | 
| TIMI flow grade after PCI |  | 180 days | 
| Time to re-hospitalization with reinfarction | Time to re-hospitalization with reinfarction as reported in Swedeheart | 180 days | 
| Time to all-cause death or re-hospitalization with myocardial infarction |  | 180 days | 
| Time to target vessel revascularization | Time to target vessel revascularization as reported in SWEDEHEART. | 180 days | 
| Time to target lesion revascularization | Time to target lesion revascularization as reported in SWEDEHEART | 180 days | 
| Time to stent thrombosis | Time to stent thrombosis as reported in SWEDEHEART. | 180 days | 
| Time to restenosis | Time to restenosis as reported in SWEDEHEART. | 180 days | 
| Time to re-hospitalization with heart failure | Time to re-hospitalization with heart failure as reported in SWEDEHEART. | 180 days | 
| Heart failure and complications of PCI during index hospitalization | Heart failure and complications of PCI during index hospitalization as reported in SWEDEHEART | 180 days | 
| Minor bleeding during index hospitalization | Minor bleeding during index hospitalization as reported in SWEDEHEART | 180 days | 
| Length of index hospital stay | Length of index hospital stay as reported in SWEDEHEART | 180 days | 
| Bail-out use of GpIIb/IIIa | Bail-out use of GpIIb/IIIa inhibitors during PCI | 180 days |