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The bivalirudin paradox: high evidence, low use
Stefano De Servi1, Giuseppe Mariani, Matteo Mariani
1Cardiovascular Department, AO Ospedale Civile, Legnano, Italy. stefano.deservi@ao-legnano.it
Journal of Cardiovascular Medicine (Hagerstown, Md.)
|February 28, 2013
Summary
Bivalirudin is a safe and effective alternative to unfractionated heparin for percutaneous coronary interventions, especially in acute coronary syndromes, reducing bleeding and mortality. Despite proven benefits, its use remains low due to operator preference for cheaper alternatives.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Bivalirudin, a direct thrombin inhibitor, offers an alternative to unfractionated heparin (UFH) in percutaneous coronary interventions (PCI).
- Its efficacy is notable in acute coronary syndromes (ACS), showing reduced adverse events and bleeding compared to UFH, particularly in ST-segment elevation myocardial infarction (STEMI).
Purpose of the Study:
- To evaluate the effectiveness and safety of bivalirudin compared to UFH in patients undergoing PCI.
- To highlight the benefits of bivalirudin in ACS patients, including STEMI and non-ST elevation myocardial infarction (NSTEMI).
Main Methods:
- Review of clinical trials including HORIZONS-AMI and ISAR REACT 4.
- Comparison of bivalirudin versus UFH (alone or with glycoprotein IIb/IIIa antagonists) in PCI patients, focusing on clinical outcomes and bleeding events.
Main Results:
- Bivalirudin significantly reduced 30-day net adverse clinical events and major bleeding in STEMI patients (HORIZONS-AMI).
- It also led to lower all-cause and cardiac mortality up to 3-year follow-up.
- In NSTEMI patients (ISAR REACT 4), bivalirudin use resulted in lower major bleeding rates compared to UFH with abciximab.
Conclusions:
- Bivalirudin is a recommended and effective treatment for ACS patients undergoing PCI, offering significant reductions in bleeding and mortality.
- Despite evidence and guidelines, bivalirudin's underutilization persists, possibly due to cost and operator preference for UFH combined with GPIs.
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