Bivalirudin holds its advantage at low bleeding risk, and two familiar drugs fail their trials

The edition in brief

Today's cardiology desk turns on four randomised results and one registry. In a prespecified BRIGHT-4 analysis of 6,016 STEMI patients treated by radial primary PCI, bivalirudin with a 2–4 hour high-dose post-procedural infusion reduced 30-day death or BARC 3–5 bleeding in patients at low bleeding risk (1.4% vs 2.9%, HR 0.49, 95% CI 0.32–0.75), while the effect in higher-risk patients was not significant (8.1% vs 9.2%, HR 0.88, 95% CI 0.62–1.26). The absolute reductions were similar in both; only the relative interaction reached significance, so the reading is that the benefit applies across bleeding risk rather than being confined to one group. The CLEAN trial randomised 1,503 STEMI patients in China to intravenous nicorandil or placebo and found no difference in the 12-month composite (13.1% in both arms, rate ratio 0.869, 95% CI 0.650–1.162), with nominal secondary reductions in cardiovascular death and target-vessel revascularisation that should not be read as findings. A Danish trial of sodium bicarbonate in 779 analysed in-hospital cardiac arrests found no difference in sustained return of spontaneous circulation (39% vs 37%, RR 1.05), with more alkalosis and hypernatremia. A Finnish registry of 40,986 patients found isolated atrial flutter carried a substantially lower ischaemic stroke rate than atrial fibrillation (adjusted IRR 0.60, 95% CI 0.49–0.74), consistent across CHA2DS2-VA categories. The edition closes on TUXEDO-2, an investigator-initiated Indian trial of 1,800 patients with diabetes and multivessel disease, in which an ultra-thin biodegradable-polymer sirolimus stent was noninferior to a durable-polymer everolimus stent at one year.