Bivalirudin in ST-segment-elevation myocardial infarction: for better or worse?

Abstract

Bivalirudin and heparin are the major available parenteral anticoagulants for percutaneous coronary intervention (PCI) in ST-segment-elevation myocardial infarction. Even though hard clinical outcomes are comparable with both drugs, bivalirudin appears to be safer (less bleeding events) at the expense of lower short-term efficacy (more acute stent thrombosis events). The selection of anticoagulation during PCI in ST-segment-elevation myocardial infarction should be individualized, taking into account the patient’s ischemic and bleeding risk. In patients with increased bleeding risk, bivalirudin might be preferable to heparin, whereas in complex PCI with increased risk for stent thrombosis, heparin is preferable. Further clinical studies are needed to elucidate the role of these drugs in PCI for ST-segment-elevation myocardial infarction in the era of radial approaches, new potent antiplatelet agents and the use of glycoprotein IIb/IIIa inhibitors.

Keywords:

• bivalirudin
• bleeding
• heparin
• stent thrombosis
• ST-segment elevation myocardial infarction

Financial & competing interests disclosure

TA Mavrakanas has received a grant from the Swiss National Science Foundation. YS Chatzizisis has received a grant from the Behrakis Foundation, Boston, MA, USA. The authors have no other 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 apart from those disclosed.

Key issues

• Composite hard clinical outcomes appear to be comparable with both drugs. Current evidence suggests that bivalirudin is associated with a safety benefit (less major bleeding events) at the expense of lower short-term efficacy (more acute stent thrombosis events).

• Anticoagulation management during PCI in STEMI should be individualized, taking into account patient’s ischemic and bleeding risk. In patients with increased bleeding risk, bivalirudin appears to be preferable to heparin, whereas in complex PCI with increased risk for stent thrombosis, heparin might be more preferable. The significantly higher cost of bivalirudin compared with heparin should be also taken into account.

• Further clinical studies are needed to elucidate the role of these drugs in STEMI PCI in the era of radial approach, new potent antiplatelet agents and provisional glycoprotein IIb/IIIa inhibitors use.