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After ISAR REACT 4, will bivalirudin remain the 'ex-Mr Kardashian' of the PCI world?Nov 13, 2011 21:05 EST
No matter how good it looks, how well it works, how cheap it is, how easy to utilize, bivalirudin just can't seem to stay in a relationship at many PCI centers. "No one uses it at my hospital," said a journalist in the pressroom today, who also works in an acute-care setting. "No one uses it in my hospital either," I lamented, "and I've rarely seen it utilized in the other centers that PCI my patients as well." It seems to be reserved as a backup plan in those with bleeding potential, so it sits on some faraway, forgotten dusty shelf in the back of the hospital pharmacy just hoping for an opportunity to prove its worth. Despite the fact that, in ISAR-REACT 4, abciximab combined with unfractionated heparin failed to reduce death, recurrent MI, or urgent TVR and even increased the incidence of bleeding, things probably won't change much. I insist that bivalirudin, its comparator in this study deserves a second look; instead, it's like that guy in high school who could never get a date. When he did finally get a girl to say yes, he was told at the end of the evening, "I just want to be friends." If a vial of bivalirudin could only speak to an interventionalist, the conversation might be similar to what I would expect occurred between pop icon and hapless romantic Kim Kardashian when she filed for a divorce from her latest "ex" after a long 72 days of marriage. I would expect it went something like this:
Bivalirudin: What can I do? Is there anything I can change? Is it my packaging? My age? Is the dose difficult to remember? Is it cost? I promise I'll change. I'll do anything to make this work. Just give me a chance.
Interventionalist: Gee, it's not really you. You haven't done anything wrong. I'm just not feelin' it.
Bivalirudin: From a patient perspective would you rather have a two-hour infusion of me during a procedure or remain tethered to a drip of that abciximab stuff for 12 hours?
Bivalirudin: Is it the cost? It's surely not the cost thing.
Interventionalist: I don't know how much anything in American medicine costs, so it's not that.
Bivalirudin: So, I know what it is . . . go ahead, just say it. It's something from my past . . . the HORIZONS trial, isn't it? It's that thing with early stent thrombosis! I'm telling you, it isn't the way it looked!
The interventionalist hesitates, hangs his head and starts to slowly walk away. The vial of bivalirudin watches him longingly. The interventionalist stops and looks back to say, "It's just that, well. . . . This is never going to work. . . . You and I . . . I just can't explain it. I'm so sorry. . . . It's just not going to work, okay?"
Dr Gregg Stone told heartwire's Sue Hughes, way back in 2007, that "major bleeding as defined in HORIZONS had virtually the same impact on mortality as did definite stent thrombosis, and since major bleeding was more common than stent thrombosis, bivalirudin-assigned patients had lower mortality." Furthermore, the hospital cost of a dose of abciximab for 12 hours is around $1424 dollars, vs $1365 for bivalirudin (interestingly, the patient cost was 3.7 times greater for both of them).
In most places where bivalirudin has been able to prove itself, it doesn't seem to fare any better than the latest reality-show conquest. Like the latest "ex–Mr Kardashian," it can't seem to stay in a relationship, but unlike that unfortunate fellow who just couldn't seem to do anything right, bivalirudin is Mr Perfect; still, no one wants to take him home.