Dynamic Coronary Roadmap versus standard angiography for percutaneous coronary intervention: the randomised, multicentre DCR4Contrast trial.

BACKGROUND: Decreasing the amount of iodinated contrast is an important safety aspect of percutaneous coronary interventions (PCI), particularly in patients with a high risk of contrast-induced acute kidney injury (CI-AKI). Dynamic Coronary Roadmap (DCR) is a PCI navigation support tool projecting a motion-compensated virtual coronary roadmap overlay on fluoroscopy, potentially limiting the need for contrast during PCI. AIMS: This study investigates the contrast-sparing potential of DCR in PCI, compared to standard angiographic guidance. METHODS: The Dynamic Coronary Roadmap for Contrast Reduction (DCR4Contrast) trial is a multicentre, international, prospective, unblinded, stratified 1:1 randomised controlled trial. Patients were randomised to either DCR-guided PCI or to conventional angiography-guided PCI. The primary endpoint was the total volume of iodinated contrast administered, and the secondary endpoint was the number of cineangiography runs during PCI. RESULTS: The study population included 356 randomised patients (179 in DCR and 177 in control groups, respectively). There were no differences in patient demographics, angiographic characteristics or estimated glomerular filtration rate (eGFR) between the two groups. The total contrast volume used during PCI was significantly lower with DCR guidance compared with conventional angiographic guidance (64.6±44.4 ml vs 90.8±55.4 ml, respectively; p<0.001). The total number of cineangiography runs was also significantly reduced in the DCR group (8.7±4.7 vs 11.7±7.6 in the control group; p<0.001). CONCLUSIONS: Compared to conventional angiography-guided PCI, DCR guidance was associated with a significant reduction in both contrast volume and the number of cineangiography runs during PCI. (ClinicalTrials.gov: NCT04085614).

¿Bivalirudina o heparina asociada a inhibidores de la glucoproteína IIb/IIIa en el síndrome coronario agudo sin elevación del ST? / Bivalirudin or heparin plus glycoprotein-IIb/IIIa inhibitors for non-ST-elevation acute coronary syndrome?

La bivalirudina, análogo sintético de la hirudina que se une reversiblemente a la trombina, pertenece al grupo de anticoagulantes que son inhibidores directos de la trombina con un efecto muy predecible. El objetivo de esta revisión es responder a la pregunta: ¿cuáles son la eficacia y la seguridad del tratamiento con bivalirudina en pacientes con síndrome coronario agudo sin elevación del ST, en comparación con la combinación de heparina (no fraccionada o de bajo peso molecular) e inhibidores de la glucoproteína IIb/ IIIa? Ambas estrategias han sido comparadas en dos estudios (ACUITY y REPLACE-2), de diseño e interpretación difícil, y que han mostrado una eficacia en términos de prevención de eventos cardiacos similar y disminución de las complicaciones hemorrágicas en los grupos asignados a recibir tratamiento con bivalirudina. Se realiza un análisis crítico de las evidencias y de las limitaciones existentes, que pueden servir de base para implantar una u otra estrategia en los protocolos de manejo del síndrome coronario agudo sin elevación del ST (AU)

Bivalirudin is a synthetic analog of hirudin that binds reversibly to thrombin. It belongs to a group of anticoagulants that act as direct thrombin inhibitors and whose effect is highly predictable. The aim of this review was to answer the question: How does the efficacy and safety of bivalirudin in patients with nonST-elevation acute coronary syndrome compare with that of the combination of (unfractionated or lowmolecular-weight) heparin and a glycoprotein-IIb/IIIa inhibitor? The two treatment strategies have been compared in two studies (i.e. ACUITY and REPLACE-2), both of which had a complex design and were difficult to interpret. These studies demonstrated that the two treatment strategies had similar efficacy in terms of preventing cardiac events and that fewer hemorrhagic complications occurred in the groups assigned to bivalirudin. We carried out a thorough analysis of the data available and their limitations, the results of which can serve as a basis for implementing one or other strategy in treatment protocols for nonST-elevation acute coronary síndrome (AU)