Percutaneous coronary intervention in patients with acute coronary syndrome: focus on bivalirudin

Figures & data

Figure 1 The coagulation cascade in atherothrombosis. Reprinted with permission from Arora UK, Dhir M. 2005. Direct thrombin inhibitors part 1 of 2. J Invasive Cardiol, 17:34–8. Copyright © 2005 HMP Communications.

Abbreviations: F, factor; T, tissue.

Figure 2 Bivalirudin’s action on thrombin. Reprinted with permission from Di Nisio M, Middeldorp S, Buller HR. 2005. Direct thrombin inhibitors. N Engl J Med, 353:1028–40. Copyright © 2005 Massachusetts Medical Society. All rights reserved.

Figure 3 Structure of bivalirudin. Reprinted with permission from Sciulli TM, Mauro VF. 2002. Pharmacology and clinical use of bivalirudin. Ann Pharmacother, 36:1028–41. Copright © 2002 Harvey Whitney Books Co.

Table 1 Current dosage recommendations for bivalirudin for various patient subpopulations

Patient subgroup	Initial bolus (mg/kg)	Infusion during PCI (mg/kg/hr)
Normal renal function (>90 mL/mina)	0.75	1.75
Mild renal impairment (60–90 mL/mina)	0.75	1.75
Moderate renal impairment (30–59 mL/mina)	0.75	1.75
Severe renal impairment (10–29 mL/mina)	0.75	1.00
Dialysis-dependent	0.75	0.25
HIT/HITTS undergoing PCI	0.75	1.75

a Renal function based on estimated glomerular filtration rate (GFR).

Abbreviations: HIT/HITTS, heparin-induced thrombocytopenia/heparin-induced thrombocytopenia with thrombotic syndrome; PCI, percutaneous coronary intervention.

Figure 4 Scanning electron photomicrographs representing differences in platelet activation between anticoagulants. (A) normal platelet at rest, (B) platelet response to bivalirudin therapy, (C) platelet response and activation with UFH therapy, (D) platelet response (release of microparticles) after UFH therapy. Reprinted with permission from Anand SX, Kim MC, Kamran M, et al. 2007. Comparison of platelet function and morphology in patients undergoing percutaneous coronary intervention receiving bivalirudin versus unfractionated heparin versus clopidogrel pretreatment and bivalirudin. Am J Cardiol, 100:417–24. Copyright © 2007 Elsevier.

Table 2 Guideline-based indications for the use of bivalirudin in ACS patients (Anderson et al 2007; King et al 2007)

Clinical setting	Description	ACC/AHA indication
HIT/HITTS	For patients with known HIT/HITTS and undergoing PCI or CABG.	Class I
USA/NSTEMI	For patients in whom an invasive strategy is selected, bivalirudin is started upon hospital presentation.	Class I, LOE B
	For patients in whom PCI has been selected as a post-angiography management strategy, bivalirudin is used with at least 300 mg of clopidogrel administered at least 6 h earlier.	Class IIa, LOE B
	For patients in whom PCI has been selected as a post-angiography management strategy, bivalirudin is used with a GPIIbIIIa inhibitors if at least 300 mg of clopidogrel was NOT administered at least 6 h earlier.	Class IIa, LOE B
	For patients in whom a conservative strategy is selected, bivalirudin is started upon hospital presentation.	No current recommendation.
STEMI	For patients undergoing primary PCI or Rescue PCI, bivalirudin is started prior to intervention.	No current recommendation.
	For patients undergoing primary PCI or Rescue PCI who have received UFH up to the time of intervention, bivalirudin is used during the intervention.	Class I, LOE C

Abbreviations: ACC/AHA, American College of Cardiology/American Heart Association; ACS, acute coronary syndrome; CABG, coronary artery bypass surgery; HIT/HITTS, heparin-induced thrombocytopenia/heparin-induced thrombocytopenia with thrombotic syndrome; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; NSTEMI, non-ST-elevation myocardial infarction; USA, unstable angina.

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