Impact of Worsening Renal Dysfunction on the Comparative Efficacy of Bivalirudin and Platelet Glycoprotein IIb/IIIa Inhibitors

Background— Use of bivalirudin has been associated with a reduction in the incidence of bleeding in patients undergoing percutaneous coronary intervention. Patients with chronic kidney disease, a known predictor of post–percutaneous coronary intervention bleeding, are under-represented in clinical trials. Methods and Results— We evaluated the outcome of 64 052 patients who underwent percutaneous coronary intervention from 2007 to 2009 at 33 hospitals in Michigan and were treated with bivalirudin (28 378) or with heparin and glycoprotein IIb/IIIa inhibitors (35 674). Propensity-matched analysis was adjusted for the nonrandomized use of the 2 strategies. Patients treated with bivalirudin were older, had a lower glomerular filtration rate, and had more comorbidities. Use of bivalirudin was associated with fewer transfusions (2.8% versus 4.2%; P <0.0001), gastrointestinal bleeds (0.5% versus 1.3%; P <0.0001), and vascular complications (1.0% versus 2.5%; P <0.0001), with no difference in survival. Bleeding complications were more common with worsening renal function, but use of bivalirudin was associated with less bleeding across the continuum of renal dysfunction. Conclusions— The risk of bleeding after percutaneous coronary intervention increases with worsening chronic kidney disease. Bivalirudin was associated with a dramatically reduced risk of bleeding across all categories of renal dysfunction. Our study findings suggest that bivalirudin monotherapy is an acceptable, if not the more appropriate alternative, to heparin and glycoprotein IIb/IIIa inhibitors in patients with chronic kidney disease.