Direct thrombin inhibition during percutaneous coronary intervention in patients with heparin-induced thrombocytopenia

Abstract

Patients with or at risk of heparin-induced thrombocytopenia (HIT) who are undergoing percutaneous coronary intervention (PCI) are at particular risk of thrombosis due to the prothrombotic nature of HIT and the endovascular disruption from PCI. Patients require aggressive anticoagulation during PCI, and alternative, nonheparin anticoagulation is recommended over heparin in patients with acute or previous HIT. Argatroban, bivalirudin, and lepirudin are nonheparin, fast-acting, parenteral direct thrombin inhibitors (DTIs). Multicenter, prospective studies have demonstrated that argatroban and lepirudin each reduce thrombosis in HIT and that argatroban and bivalirudin each provide adequate anticoagulation during PCI in patients with or at risk of HIT. We review current therapeutic practices with direct thrombin inhibitors in patients with or at risk of HIT during PCI, including individuals requiring periprocedural anticoagulation, and the factors influencing the choice of DTI in this setting.

Keywords::

• anticoagulant
• argatroban
• bivalirudin
• direct thrombin inhibitor
• heparin
• heparin-induced thrombocytopenia
• lepirudin
• percutaneous coronary intervention
• thrombus

Conflict of interest

Dr Lewis has received consultancy fees from GlaxoSmithKline. Dr Hursting has received consultancy fees from GlaxoSmithKline.