Bivalirudin during percutaneous coronary intervention in acute coronary syndromes

ABSTRACT

Introduction: Anticoagulant therapy is critical to prevent ischemic recurrences and complications in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). Unfractionated heparin (UFH), an injectable anticoagulant has several limitations: lack of predictability of its biological efficacy, platelets activation, heparin-induced thrombopenia and bleedings. Bivalirudin, a synthetic direct thrombin inhibitor has biological properties that promised better clinical outcome in ACS patients undergoing PCI.

Areas covered: The present review aimed to summarize two decades of randomized clinical trials that compared bivalirudin to UFH in ACS patients treated with PCI. Early trials highlighted a reduction of bleedings with bivalirudin compared to UFH in combination with glycoprotein inhibitors (GPI). Recent studies questioned this reduction given that GPI are less and less used during PCI. Further, trials raised concerns about the risk of stent thrombosis in patients treated with bivalirudin. In light of this data, bivalirudin has been downgraded in international guidelines and appears as a second line anticoagulant agent after UFH.

Expert opinion: The highly questioned reduction of bleedings under bivalirudin and the potential risk of stent thrombosis are unwarranted. Based on clinical trials, UFH has no equivalent in terms of anticoagulation in ACS patients undergoing PCI.

KEYWORDS:

• Bivalirudin
• unfractionated heparin
• acute coronary syndrome
• percutaneous coronary intervention

Article highlights

• Anticoagulant is critical in ACS patients undergoing PCI to prevent ischemic recurrences

• Bivalirudin has pharmacological advantages compared to UFH: direct thrombin inhibition, predictable biological efficacy, and platelet reactivity inhibition.

• Early trials have demonstrated a reduction of bleedings with bivalirudin mainly because of the use of glycoprotein inhibitorsin the control group.

• Bivalirudin use has repeatedly been associated with stent thrombosis, a dramatic complication of PCI.

• International guidelines recommend the use of UFH as first line agent (class I), bivalirudin is relegated as a second line agent.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Additional information

Funding

This manuscript was not funded.