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The role of bivalirudin in percutaneous coronary intervention 

The role of bivalirudin in percutaneous coronary intervention
Chapter:
The role of bivalirudin in percutaneous coronary intervention
Author(s):

Steffen Massberg

, Julinda Mehilli

, and Adnan Kastrati

DOI:
10.1093/med/9780199569083.003.025
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date: 01 December 2020

Rapid progress has been made in interventional cardiology over the past years, and many patients with coronary artery disease, even those with complex lesions, are nowadays being treated with percutaneous coronary interventions (PCI). As a result, a major focus of current cardiovascular research is on reducing negative peri-procedural clinical events associated with PCI, particularly in high-risk patients. Among the most dangerous peri-procedural events are thrombotic complications, leading to recurrent myocardial or cerebral ischaemia, often with fatal outcome. Anticoagulant and antithrombotic treatment, therefore, is an integral part of current PCI strategies. It is needless to say that prevention of procedural thrombotic events with the use of anticoagulants occurs at the expense of severe bleeding complications. Hence, there has been a strong effort over recent years to develop and validate novel anticoagulant regimens that provide protection against thrombotic complications, but have only minor effects on normal haemostasis.

Until recently, the standard anticoagulation therapy during PCI consisted in either unfractionated (UFH) or low-molecular-weight heparin (LMWH) that prevent coagulation indirectly by activation of antithrombin (AT). Once activated, AT inactivates thrombin and other proteases involved in blood clotting. However, only recently direct thrombin inhibitors (DTI) have been introduced as an alternative anticoagulant strategy in patients undergoing PCI. Bivalirudin is the most prominent member of the DTI class, directly inhibiting free- and clot-bound thrombin. Use of bivalirudin has recently been shown to result in a significant reduction of bleeding without an increase in thrombotic or ischaemic endpoints compared to heparin and glycoprotein (GP) IIb/IIIa inhibitors in patients presenting with acute coronary syndromes (ACS).

This chapter will give an overview of the pharmacology and mechanism of action of bivalirudin and summarize results from recent clinical trials evaluating the use of bivalirudin in patients undergoing PCI.

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