Pharmacological Adjuvant Therapies in Primary Coronary Interventions: Bivalirudin
Alessandro Lupi, Andrea Rognoni, Chiara Cavallino, Gioel G. Secco, Maria D. Prando, Matteo Santagostino, Maurizio Lazzero, Ettore Cassetti and Angelo S. Bongo
Affiliation: Coronary Care Unit and Catheterization Laboratory, Hospital “Maggiore della Carita”, Corso Mazzini 18, 28100 Novara, Italy.
Keywords: Bivalirudin, STEMI, primary PCI, heparin, abciximab, GP2b3a inhibitors, bleeding, adjuvant therapy, coronary
intervention, acute coronary syndrome.
The direct thrombin inhibitor bivalirudin has gained popularity in cardiovascular medicine over the past
decade because, in comparison with unfractionated heparin, it guarantees a predictable dose-related degree of
anticoagulation with a low immunogenic profile and, possibly, with reduced rates of major bleeding complications.
In the past bivalirudin has been frequently employed in the management of patients with heparin-induced
thrombocytopenia. The REPLACE-2, ACUITY and ISAR-REACT4 studies demonstrated bivalirudin non-inferiority in
comparison with unfractionated heparin in terms of ischemic end-points with a reduction of the bleeding rate also in
patients acute coronary syndrome without ST elevation. Finally the results of the HORIZONS-AMI study positioned this
drug as a first choice anticoagulant during percutaneous coronary interventions in patients with ST-elevation myocardial
infarction. In fact the bivalirudin alone regimen, compared to unfractionated heparin plus GP2b3a inhibitors, decreased inhospital
bleeding rates and short and long term mortality. Given the body of clinical evidence, bivalirudin is likely to
contend to GP2b3a inhibitors the leading place among the proposed anticoagulation strategies in the setting of acute
coronary syndromes. The duration of the bivalirudin infusion after PCI and the optimal oral antiplatelet regimen
associated to bivalirudin are important issues to be solved in future randomized controlled studies.
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