Bivalirudin in the Treatment of Coronary Artery Disease

Rohan Jayasinghe, Ryan Maxwell, Vaishnavi Sridhar



Periprocedural anticoagulation continues to be a vital aspect in the management of coronary artery disease. Bivalirudin is a relatively new drug that has caught much attention in the last decade, especially in the context of percutaneous coronary intervention for acute coronary syndromes. Multiple clinical trials have shown the efficacy, safety profile and limitations of bivalirudin in contrast to previously used heparin and glycoprotein IIb/IIIa inhibitors. These trials have included patients with moderate to high-risk stable angina, unstable angina, non-ST-elevation and ST-elevation myocardial infarctions requiring PCI. The growing body of evidence on bivalirudin has also improved the understanding of its applicability and efficacy over other hirudin-based anticoagulants, however continual review of more recent evidence is important in order to integrate bivalirudin more widely across the various guidelines. This article aims to study the cross-section of the evidence base to date on the clinical use, efficacy and risks related to the use of bivalirudin and attempts to provide the clinician with a practical overview of the role of bivalirudin in the most recent guidelines.


Bivalirudin; Direct Thrombin Inhibitors; Anticoagulants; Acute Coronary Syndromes

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  • Angiomax - FDA approved drug products. 2013. Available from: (last accessed July 2013)
  • Kushner FG, Hand M, Smith SC, et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2009; 54: 2205-41;
  • Anderson JL, Adams CD, Antman EM, et al. 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 123: e426-579;
  • Harrington RA, Becker RC, Cannon CP, et al. Antithrombotic Therapy for Non-ST-Segment Elevation Acute Coronary Syndromes: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest 2008; 133(6 Suppl): 670S-707S;
  • Silber S, Albertsson P, Avilés FF, et al. (2005). Guidelines for Percutaneous Coronary Interventions: the Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 2005; 26: 804-47;
  • Task Force for Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of European Society of Cardiology, Bassand JP, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology. Eur Heart J 2007; 28: 1598-660;
  • Van de Werf F, Bax J, Betriu A, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology. Eur Heart J 2008; 29: 2909-45;
  • Stone GW, McLaurin BT, Cox DA, et al. Bivalirudin for Patients With Acute Coronary Syndromes. N Engl J Med 2006; 355: 2203-16;
  • Warkentin TE, Greinacher A, Koster A. Bivalirudin. Thromb Haemost 2008; 99: 830-9
  • Warkentin TE, Greinacher A, Craven S, et al. Differences in the clinically effective molar concentrations of four direct thrombin inhibitors explain their variable prothrombin time prolongation. Thromb Haemost 2005; 94: 958-4
  • Warkentin TE. Bivalent direct thrombin inhibitors. Best Pract Res Clin Haematol 2004; 17: 105-25;
  • Koster A, Chew D, Gründel M, et al. An Assessment of different filter systems for extracorporeal elimination of bivalirudin: an in virtro study. Anaesth Analg 2003; 96: 1316-9;
  • Ramana RK, Lewis BE. Percutaneous Coronary Intervention in patients with acute coronary syndrome: focus on bivalirudin. Vasc Health Risk Manag 2008; 4: 493-505
  • Fox I, Dawson A, Loynds P, et al. Anticoagulation activity of Hirulog, a direct thrombin inhibitor, in humans. Thromb Haemost 1993; 69: 157-63
  • Cannon CP, Maraganore JM, Loscalzo J, et al. Anticoagulant effects of hirulog, a novel thrombin inhibitor, in patients with coronary artery disease. Am J Cardiol 1993; 71: 778-82;
  • Lidon RM, Theroux P, Juneau M, et al. Initial experience with a direct antithrombin, Hirulog, in unstable angina. Anticoagulant, antithrombotic, and clinical effects. Circulation 1993; 88: 1495-501;
  • Robson R. The use of bivalirudin in patients with renal impairment. J Invasive Cardiol 2000; 12(Suppl F): 33F-6
  • Stone GW, Witzenbichler B, Guagliumi G, et al. Bivalirudin during Primary PCI in Acute Myocardial Infarction. N Engl J Med 2008, 358; 2218-30;
  • Lincoff AM, Bittl JA, Harrington RA, et al. Bivalirudin and provisional glycoprotein IIb/IIIa blockade compared with heparin and planned glycoprotein IIb/IIIa blockade during primary percutaneous coronary intervention: REPLACE-2 randomized trial. JAMA 2003; 289: 853-63;
  • Feit F, Voeltz MD, Attubato MJ, et al. Predictors and impact of major haemorrhage on mortality following percutaneous coronary intervention from the REPLACE-2 trial. Am J Cardiol 2007; 100: 1364-69;
  • White HD, Chew DP, Hoekstra JW, et al. Safety and Efficacy of Switching form either Unfractionated Heparin or Enoxaparin to Bivalirudin in patients with non-ST-segment elevation acute coronary syndromes managed with an invasive strategy. J Am Coll Cardiol 2008: 1734-41;
  • Kastrati A, Neumann F, Schulz S, et al. Abciximab and heparin versus bivalirudin for non-ST elevation MI. N Engl J Med 2011; 365: 1980-9;
  • Bittl JA, Chaitman BR, Feit F, et al. Bivalirudin versus heparin during coronary angioplasty for unstable or postinfarction angina: final report reanalysis of the Bivalirudin Angioplasty Study. Am Heart J 2001; 142: 952-9;
  • Casserly IP, Kereiakes DJ, Gray WA, et al. Point-of-care ecarin clotting time versus activated clotting time in correlation with bivalirudin concentration. Thromb Res 2004; 113: 115-21;
  • Measday MZ, Zucker ML, Pan CM, et al. Optimizing management of hirudin anticoagulation. J Extra Corpor Technol 2005; 37: 66-70
  • Anderson PR, Gogo PB, Ahmed B, et al. Two hour bivalirudin infusion after PCI for ST elevation myocardial infarction. J Thromb Thrombolysis 2011; 31: 401-6;
  • Smedira NG, Dyke CM, Koster A, et al. Anticoagulation with bivalirudin for off-pump coronary artery bypass grafting: the results of the EVOLUTION-OFF study. J Thorac Cardiovasc Surg 2006; 131: 686-92;
  • Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia and cardiac surgery. Ann Thorac Surg 2003; 76: 2121-31;
  • Jayasinghe R, Maxwell R, Murdoch D. Abciximab in the treatment of coronary artery disease. Reviews in Health Care 2013; 4: 75-89;
  • Curtis BR, Swyers J, Divgi A, et al. Thrombocytopaenia after second exposure to abciximab is caused by antibodies that recognize abciximab-coated platelets. Blood 2002; 99: 2054-9;
  • Dasgupta H, Blankship JC, Wood GC, et al. Thrombocytopenia complicating treatment with intravenous glycoprotein IIb/IIIa receptor inhibitors: a pooled analysis. Am Heart J 2000; 140: 206-11;
  • Boehrer JD, Kereiakes DJ, Navetta FI, et al. Effects of profound platelet inhibition with c7E3 before coronary angioplasty on complications of coronary bypass surgery. Am J Cardiol 1994; 74: 1166-70;
  • Aguirre FV, Topol EJ, Ferguson JJ, et al. Bleeding complications with the chimeric antibody to platelet glycoprotein IIb/IIIa integrin in patients undergoing percutaneous coronary intervention. Circulation 1995; 91: 2882-90;
  • Booth JA, Patel VBm, Balog C, et al. Is nleeding risk increased in patients undergoing urgent coronary bypass surgery following abciximab? Circulation 1998; 98(Suppl): 845
  • Bracey A, Radovancevic R, Vaugh W, et al. Blood use in emergency coronary artery bypass after receipt of abciximab during angioplasty. Transfusion 1998: S250
  • Alvarez JM. Emergency coronary bypass grafting for failed percutaneous coronary artery stenting. J Thorac Cardiovasc Surg 1998; 115: 472-3;
  • Steg PG, Hof A, Hamm CW, et al. Bivalirudin Started during Emergency Transport for Primary PCI. N Engl J Med 2013; 369: 2207-17;
  • Antmann EM, Anbe DT, Armstrong PW, et al. ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction – Executive Summary. Circulation 2004; 110: 588-636;
  • Kushner FG, Hand M, Smith SC, et al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update). J Am Coll Cardiol 2009; 54: 2205-41;
  • White H, Hirulog and Early Reperfusion or Occlusion (HERO)-2 Trial Investigators. Thrombin-specific anticoagulation with bivalirudin versus heparin in patients receiving fibrinolytic therapy for acute myocardial infarction: the HERO-2 randomised trial. Lancet 2001; 358: 1855-63;
  • Steg G, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012; 33: 2569-619;
  • Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention. J Am Coll Cardiol 201; 58: e44-e122;


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