Introduction: Bivalirudin and heparin are the two most commonly used anticoagulants
used during Percutaneous Coronary Intervention (PCI). The results of Randomized Controlled
Trials (RCTs) comparing bivalirudin versus heparin monotherapy in the era of radial access are
controversial, questioning the positive impact of bivalirudin on bleeding. The purpose of this
systematic review is to summarize the results of RCTs comparing the efficacy and safety of
bivalirudin versus heparin with or without Glycoprotein IIb/IIIa Inhibitors (GPI).
Methods: This systematic review was performed in accordance with Preferred Reporting Items for
Systematic Reviews and Meta-Analyses PRISMA statements for reporting systematic reviews. We
searched the National Library of Medicine PubMed, Clinicaltrial.gov and the Cochrane Central
Register of Controlled Trials to include clinical studies comparing bivalirudin with heparin in
patients undergoing PCI. Sixteen studies met inclusion criteria and were reviewed for the summary.
Findings: Several RCTs and meta-analyses have demonstrated the superiority of bivalirudin over
heparin plus routine GPI use in terms of preventing bleeding complications but at the expense of
increased risk of ischemic complications such as stent thrombosis. The hypothesis of post- PCI
bivalirudin infusion to mitigate the risk of acute stent thrombosis has been tested in various RCTs
with conflicting results. In comparison, heparin offers the advantage of having a reversible agent, of
lower cost and reduced incidence of ischemic complications.
Conclusion: Bivalirudin demonstrates its superiority over heparin plus GPI with better clinical
outcomes in terms of less bleeding complications, thus making it as anticoagulation of choice
particularly in patients at high risk of bleeding. Further studies are warranted for head to head
comparison of bivalirudin to heparin monotherapy to establish an optimal heparin dosing regimen
and post-PCI bivalirudin infusion to affirm its beneficial effect in reducing acute stent thrombosis.