Bivalirudin Versus Heparin During PCI in High Bleeding Risk Patients With Acute Coronary Syndromes

Study design BRIGHT-HBR is an investigator-sponsored, prospective, multicenter, open-label, active-controlled randomized trial. A total of 5,270 patients with NSTE-ACS and stabilized recent STEMI who are at HBR and are undergoing PCI with radial artery access will be enrolled at 70 sites in China. Patients are randomized 1:1 to two arms: bivalirudin vs. UFH monotherapy, with GPI reserved for bailout use in each group. The trial is powered to demonstrate the superiority of bivalirudin compared with UFH in reducing the 30-day rate of net adverse clinical events (NACE), the composite of all-cause death, MI, stroke, urgent target-vessel revascularization, or bleeding according to the Bleeding Academic Research Consortium (BARC) types 2, 3 or 5 criteria.

Randomization and study treatment Before diagnostic angiography, eligible patients will be randomly assigned in a 1:1 ratio to procedural anticoagulation with bivalirudin or UFH monotherapy. Allocation to treatment will be provided by an interactive web response system in randomly permuted block sizes of 4 or 6, with stratification according to the participating center, which is incorporated within an electronic data capture system.

In the UFH monotherapy group, an intravenous UFH bolus of 70 U/kg will be administered. The ACT will be measured 5 minutes after the first administration, and if the ACT is <250 seconds (Hemotec assay), an additional intravenous bolus of 1000 U UFH will be administered, to ensure the re-checked ACT is ≥250 seconds prior to PCI.

In the bivalirudin group, an intravenous bolus dose of bivalirudin 0.75 mg/kg will be administered, followed by an intravenous infusion of 1.75 mg/(kg·h). The infusion dose (but not the bolus) is adjusted for renal insufficiency. The estimated glomerular filtration rate (eGFR) will be calculated by the formula: 186 × (serum creatinine [mg/dL])-1.154 × (age)-0.203 × (0.742 if female). For patients with moderate renal impairment (eGFR 30-59 ml/(min·1.73m2), the intravenous infusion dose is unchanged; for patients with severe renal impairment (eGFR <30 ml/(min·1.73m2), the intravenous infusion dose is reduced to 1.0 mg/(kg·h); for patients undergoing dialysis, the intravenous infusion dose is reduced to 0.25 mg/(kg·h). The ACT will be monitored 5 minutes after the first bivalirudin bolus administration, and if the ACT is <250 seconds (Hemotec assay), an additional intravenous bolus of 0.3 mg/kg of bivalirudin will be administered to ensure the re-checked ACT is ≥250 seconds prior to PCI. The intravenous bivalirudin infusion is discontinued immediately after PCI.

The PCI procedure is performed using standard techniques. Radial artery access is strongly recommended. PCI is recommended for vessels with a visually assessed coronary artery diameter ≥2.5 mm with stenosis ≥70% or fractional flow reserve (FFR) <0.80 or ulcerated plaques. Complete revascularization is recommended if it may be safely achieved. PCI of chronic total occlusions (CTO) that are well-collateralized and supply viable myocardium is recommended if, in the opinion of an experienced CTO operator, there is a high likelihood of PCI success without complications or excessive contrast use. Drug-eluting stents should be used absent contraindications. Declaration of the target vessels will be made before PCI. A planned staged procedure in patients with complex or multivessel disease may be completed within 45 days and will not be considered an endpoint event. The intent to stage must be declared and documented at the end of the first procedure. The anticoagulation regimen during the planned staged procedure must be identical with that of the initial procedure. Any unplanned treatment, or a planned reintervention after 45 days will be considered an endpoint event.