Anti-thrombotic therapy remains a cornerstone in per-cutaneous coronary intervention (PCI) and acute coronary syndrome (ACS) management. The search for newer anti-thrombotic drugs is ongoing with the goal to achieve an agent which leads to less bleeding complications without a reduction or indeed improvement in clinical efficacy, resulting in net clinical benefit. This is because major bleeding remains a significant risk factor for mortality following PCI with higher 30 days and one year mortality reported in numerous studies . Bleeding is associated with a five-fold increase in mor-tality and higher risk of myocardial infarction, stroke and stent thrombosis in ACS .

1. BIVALIRUDIN IN ACUTE CORONARY
SYNDROMES AND PERCUTANEOUS
CORONARY INTERVENTION: SHOULD WE
USE IT?
Yuli Ten, FRACP,∗ and Gerard Devlin, FRACP
Australian and New Zealand Society of Cardiac and
Thoracic Surgeons (ANZSCTS) and the Cardiac Society of
Australia and New Zealand (CSANZ)
Heart, Lung and Circulation 2013;22:793–800

2. BACKGROUND
 Anti-thrombotic therapy remains a cornerstone in per-
cutaneous coronary intervention (PCI) and acute coronary
syndrome (ACS) management.
 The search for newer anti-thrombotic drugs is ongoing
with the goal to achieve an agent which leads to less
bleeding complications without a reduction or indeed
improvement in clinical efficacy, resulting in net clinical
benefit.
 This is because major bleeding remains a significant risk
factor for mortality following PCI with higher 30 days and
one year mortality reported in numerous studies .
 Bleeding is associated with a five-fold increase in mor-
tality and higher risk of myocardial infarction, stroke and
stent thrombosis in ACS .

3.  The postulated mechanisms for the increase in mortality
with major bleeding include :
 Anaemia and hypovolaemia which may contribute to
myocardial ischaemia and death;
 Bleeding may lead to discontinuation of aspirin,
clopidogrel and heparin which may predispose patients to
ischaemia, myocardial infarction, stroke and stent
thrombosis .
 In addition transfusion may increase relative tissue
hypoxia and adversely affect outcomes through stored red
blood cells acting as nitric oxide sink, which may promote
vasoconstriction, platelet aggregation and ineffective
oxygen delivery .
 With the increasing recognition that bleeding is an
important factor in patient outcomes, there has been a
shifttowards reducing bleeding risks .
 Indeed the prevention of bleeding has become as
important a goal as the prevention of ischaemia

4.  Bivalirudin is a direct and specific thrombin inhibitor
and synthetic analogue of hirudin, which has been
shown to reduce bleeding-related complications .
 It has a class 1b indication for use as an anticoagulant
during an invasive strategy .
 Bivalirudin is currently recommended as an
alternative anticoagulant in PCI.
 In the 2011 Addendum to the National Heart
Foundation of Australia/Cardiac Society of Australia
and New Zealand(CSANZ) Guidelines for the
Management of Acute Coronary Syndromes 2006,
bivalirudin is recommended in preference to
enoxaparin in the context of an invasive strategy in
patients at high risk of bleeding .
 In this article, we review the current evidence base,
which supports its use.

5. PHARMACOLOGY OF BIVALIRUDIN V. HEPARIN
 Unfractionated heparin has been the standard adjunctive
antithrombin therapy during PCI for more than 30years.
 Heparin works indirectly by binding to antithrombin III and
converts antithrombin III from a slow to a rapid inactivator of
thrombin, factors Xa, XIIa and IXa.
 The heparin–antithombin III complex inactivates free thrombin
but is unable to inactivate thrombin bound within the clot .
 A possible mechanism for this includes the inability of the bulky heparin–
antithrombin III complex to penetrate the clot.
 In addition the binding site for the heparin–antithrombin complex on
thrombin may be masked following attachment of the thrombin to fibrin.
 Heparin is inactivated by inhibitors released by platelets including
heparinase and platelet factor 4 .
 Heparin binds to tissue and plasma proteins, which makes the
bioavailability, clearance and thus dosing variable from patient to
patient . In addition it has nonlinear anticoagulant response at
therapeutic dose and a dose dependent half-life. The anticoagulant
effects thus may vary from patient to patient. Heparin also has
platelet activating effects

6.  Bivalirudin specifically binds to both the active catalytic site and
anion binding exosite of free and clot bound thrombin .
 The binding of bivalirudin to thrombin is reversible as thrombin
slowly cleaves the bivalirudin–thrombin bond resulting in
recovery of thrombin active site functions.
 Bivalirudin is able to inhibit both free and clot bound thrombin
and is not inhibited by circulating inhibitors.
 Bivalirudin does not activate platelets and in contrast inhibits
thrombin mediated platelet activation.
 Because bivalirudin binds only to thrombin and has minimal
tissue and plasma protein binding, it has predictable, dose
dependent and reliable anticoagulant effects .
 Bivalirudin exhibits linear pharmacokinetics with linear dose
and concentration proportional anticoagulant activity.
 The ACT, aPTT, TT and PT are prolonged by bivalirudin in a
dose dependent manner.
 Bivalirudin has a short half-life of 25 min and is cleared both
renally and via proteolytic degradation. Dose adjustment is thus
required in the presence of renal impairment.

8. THE EVIDENCE : ACUTE CORONARY SYNDROMES
AND PERCUTANEOUS CORONARY INTERVENTION
 In the Hirudin Angioplasty study which was
performed during the balloon angioplasty era, prior
to the routine use of thienopyridines, GP IIbIIIa
inhibitors and stenting, bivalirudin was reported to
be as effective as high dose heparin in reducing
ischaemic complications (11.8%v. 12.9%; p = 0.26) and
was associated with reduced bleeding (3.8% v. 9.8%;
p < 0.001) .
 Furthermore in a subgroup analysis of patients with
post infarction angina, bivalirudin resulted in a lower
incidence of ischaemic complications(9.1% v. 14.2%; p
= 0.04) and bleeding (3.0% v. 11.0%;p < 0.001).

9.  A meta-analysis of direct thrombin inhibitors including
bivalirudin in acute coronary syndromes by theDirect
Thrombin Inhibitors Trialists’ Collaborative Group
reviewed the use of direct thrombin inhibitors
v.unfractionated heparin for up to seven days in 35,970
patients in 11 randomised trials performed in the era prior
to the routine use of thienopyridines and GP IIbIIIa
inhibitors .
 Compared with unfractionated heparin,direct thrombin
inhibitors were associated with a lower risk of death or
myocardial infarction at 30 days [7.4% v.8.2%; odds ratio
(OR): 0.91; 95% CI: 0.84–0.99; p = 0.02] principally due to
a lower risk of myocardial infarction [2.8%v. 3.5%; OR:
0.80 (0.71–0.9); p < 0.001].
 The greatest benefit was seen in the use of direct thrombin
inhibitors in PCI with 20 events prevented per 1000
patients treated.
 Both bivalirudin and hirudin prevented death or MI.
Compared to heparin, bivalirudin was associated with a
reduction in bleeding.

10.  The role of bivalirudin in contemporary PCI was examined in
the Randomised Evaluation in PCI Linking Angiomax to
Reduced Clinical Events (REPLACE 2)trial .
 In this trial, 6010 patients undergoing elective or urgent PCI
were randomised to either bivalirudin with provisional GP
IIbIIIa inhibition (n = 2999) or heparin (65 U/kg bolus with
planned GP IIbIIIa inhibition)(n = 3011).
 Bivalirudin with provisional GP IIbIIIa inhibition was
noninferior to heparin and planned GP IIbIIIainhibition in the
primary composite endpoint of death, myocardial infarction,
urgent repeat revascularisation or in hospital major bleeding
[bivalirudin (9.2%) v. heparin and planned GP IIbIIIa inhibitor
(10.0%); OR: 0.92;95% CI: 0.77–1.09; p = 0.32].
 There was significantly less major bleeding (41% relative
reduction) with bivalirudin[bivalirudin (2.4%) v. heparin plus
GP IIbIIIa inhibition(4.1%); p < 0.001].
 At one year, there was a trend towards improved survival with
bivalirudin, a survival advantage that was more marked in the
highest risk subgroup .
 Thus in elective or low risk PCI, bivalirudin with provisional GP
IIbIIIa inhibition may be similar to heparin and planned GP
IIbIIIa inhibitor in suppressing acute ischaemic endpoints and
significantly reduces bleeding.

11.  The issue of whether bivalirudin monotherapy was non-inferior
to heparin plus planned GP IIbIIIa inhibitor in moderate to
high-risk acute coronary syndromes wasexamined in the Acute
Catheterization and Urgent Intervention Triage strategy
(ACUITY) trial .
 In this trial,13,819 patients with moder ate to high risk acute
coronary syndromes undergoing an early invasive strategy were
randomised in an open label multicentre trial to heparin plus a
GP IIbIIIa inhibitor, bivalirudin plus a GP IIbIIIa inhibitor or
bivalirudin alone.
 Bivalirudin alone compared to heparin plus a GP IIbIIIa
inhibitor was associated with similar rates of ischaemia (7.8% v.
7.3% respectively; p = 0.32; relative risk (RR): 1.03; 95% CI: 0.93–
1.24)and significantly reduced major bleeding (3.0% v. 5.7%;p <
0.001; RR: 0.53; 95% CI: 0.43–0.65) which translated to reduced
net clinical outcome of ischaemic end points and major
bleeding (10.1% v. 11.7%; p = 0.02; RR: 0.86;95% CI: 0.77–0.97).
 Bivalirudin plus a GP IIbIIIa inhibitor was similar to heparin
plus a GP IIbIIIa inhibitor in reducing ischaemic endpoints
(7.7% v. 7.3%; p = 0.39; RR:1.07; 95% CI: 0.92–1.23) with similar
bleeding endpoints(5.3% v. 5.7%; p = 0.38; RR: 0.93; 95% CI:
0.78–1.10) and net clinical outcomes (11.8% v. 11.7%; p = 0.93; RR:
1.01; 95% CI: 0.90–1.12) respectively.

12.  At one year, there was no significant difference in
composite ischaemia [heparin plus GP IIb/IIIa inhibitor
(17.8%) v. bivalirudin plusGP IIb/IIIa inhibitor (19.4%) v.
bivalirudin monotherapy(19.2%); p = NS] and mortality
between all three groups(3.2% v. 3.3% v. 3.1%; p = ns).
 This study suggests that in moderate to high risk acute
coronary syndromes, bivalirudin monotherapy may be
equivalent to heparin plus a GP IIbIIIa inhibitor in
reducing ischaemia and leads to a reduction in major
bleeding.
 Similarly in the Intracoronary Stenting and
Antithrombotic Regimen: Rapid Early Action for Coronary
Treatment4 (ISAR-REACT 4), abciximab and
unfractionated heparin as compared with bivalirudin
failed to reduce the primary endpoint of death, large
recurrent myocardial infarction, urgent target vessel
revascularisation or major bleeding within 30 days and
increased the risk of bleeding among patients with
NSTEMI who underwent an invasive strateg

13.  The role of bivalirudin in primary PCI for acute myocardial
infarction was investigated in the Harmonizing Outcomes with
Revascularization and Stents in AcuteMyocardial Infarction
(HORIZONS-AMI) .
 In thistrial, 3602 patients with ST-segment elevation
myocardial infarction who were undergoing primary PCI within
12 h were randomised in an open label manner in a 1:1 ratio to
heparin plus a GP IIbIIIa inhibitor or bivalirudin alone
 The two primary endpoints of this trial were major bleeding and
net adverse clinical events defined as the combination of major
bleeding or major adverse clinical events defined as death,
reinfarction and target vessel revascularisation for ischaemia
and stroke within 30 days.
 Primary PCI with bivalirudin compared to heparin plusGP
IIbIIIa inhibition was associated with reduced net adverse
clinical events (9.2% v. 12.1%; RR: 0.76; 95% CI:0.63–0.92; p =
0.005) due to reduced major bleeding (4.9%v. 8.3%; RR: 0.60;
95% CI: 0.46–0.77; p < 0.001).
 Thirty day death from cardiac causes (1.8% v. 2.9%; RR:
0.62;95% CI: 0.40–0.95; p = 0.03) was significantly reduced in
the bivalirudin group.
 Thirty day death from all causes(2.1% v. 3.1%; RR: 0.66; 95% CI:
0.44–1.00; p = 0.047) was not significantly different.

14.  Death from cardiac causes(including deaths from stent
thrombosis) at 30 days was reduced by an absolute 1% and a
relative reduction of37.9% in favour of bivalirudin.
 Heparin bolus was given in the emergency room to two-thirds of
the patients in the bivalirudin group with bivalirudin
commenced in the cardiac catheterisation laboratory.
 Bivalirudin significantly reduced bleeding independent of
whether heparin was given preprocedurally .
 At one year, the rate of net adverse clinical events was lower in
the bivalirudin group compared to the heparin plus GP IIbIIIa
inhibitorgroup [15.6% v. 18.3%; hazard ratio (HR): 0.83; 95%
CI:0.71–0.97; p = 0.022] due to a reduction in major bleeding in
the bivalirudin group (5.8% v. 9.2%; HR: 0.61,0.48–0.78; p <
0.0001).
 The one year MACE was similar between both groups (11.9% v.
11.9%; HR: 1.0, 0.82–1.21;p = 0.98), however, the one year rate of
cardiac mortality (2.1% v. 3.8%; HR: 0.57; 95% CI: 0.38–0.84; p =
0.005)and all cause mortality (3.5% v. 4.8%; HR: 0.71; 95%
CI:0.51–0.98; p = 0.037) were lower in the bivalirudin group.

15.  In this trial, more deaths occurred following major
bleeding (26 deaths) than either reinfarction (10
deaths) or definite stent thrombosis (five deaths).
 In conclusion the HORIZONS-AMI trial suggests that
the prevention of haemorrhagic complications
following primary PCI for STEMI is factorial in
improved short and longterm survival.
 Bivalirudin monotherapy compared to heparin
plusGP IIbaIIIa inhibitor results in reduced major
bleeding and therefore a net clinical benefit .
 In light of these findings, the CSANZ has
recommended that amongst patients undergoing
primary PCI for STEMI, bivalirudin should be
considered as an alternative to heparin and GPIIbIIIa
inhibitor

17. THE ROLE OF CLOPIDOGREL LOADING
 In the Intracoronary Stenting and Antithrombotic Regimen: Rapid
Early Action for Coronary Treatment(ISAR-REACT 3) trial,
bivalirudin was compared with unfractionated heparin alone in a
double blind trial in 4570 troponin negative, stable and unstable
angina patients undergoing PCI following pretreatment with 600 mg
loading dose of clopidogrel at least 2 h prior to the procedure.
 There was no significant difference in the primary endpoint of
composite death, myocardial infarction, urgent target vessel
revascularisation within 30 days after revascularisation or major
bleeding during hospitalisation [bivalirudin (8.3%) v. unfractionated
heparin (8.7%)(RR: 0.94; 95% CI: 0.77– 1.15; p = 0.57)].
 Major bleeding was reduced in the bivalirudin group [bivalirudin
(3.1%) v. unfractionated heparin (4.6%) (RR: 0.66; 95% CI: 0.49–
0.90;p = 0.008)].
 The results of the primary endpoint remained consistent at one year
[bivalirudin (17.1%) v. heparin(17.5%); HR: 0.98; 95% CI: 0.86–1.13; p =
0.816] (19).
 This study suggests that in low risk, troponin negative patients who
are preloaded with 600 mg of clopidogrel at least 2 h prior to PCI,
bivalirudin may not confer any additional net clinical benefit. A
reduction in major bleeding, an independent secondary endpoint,
was however observed with bivalirudin, consistent with other trials

18.  In the ACUITY trial, patients who were not pretreated
with clopidogrel were noted to have more ischaemic
endpoints with bivalirudin monotherapy than with
unfractionated heparin/enoxaparin plus GP IIbIIIa
inhibitor (9.1% v. 7.1%; RR: 1.29; 95% CI: 1.03–1.63;p =
0.054) [12].
 In patients pretreated with clopidogrel however,
bivalirudin monotherapy resulted in similar ischaemic
endpoints to heparin plus GP IIbIIIa inhibitor(7.0% v.
7.3% respectively; RR: 0.97; 95% CI: 0.80–1.17).
 The suboptimal results in patients not pretreated with
clopidogrel implies that platelet inhibition remains
important even with potent antithrombin activity and
emphasises the importance of clopidogrel pretreatment in
all high risk acute coronary syndrome patients undergoing
an invasive strategy .
 The updated ACC/AHA guidelines recommend that
bivalirudin is a reasonable anticoagulant for PCI in
patients preloaded with clopidogrel.

19.  A 600 mg loading dose of clopidogrel has been
associated with greater and more rapid inhibition of
platelet aggregation and therefore less ischaemia
compared to a 300 mg dose .
 In a substudy from the HORIZONS-AMI trial, a 600
mg loading dose in comparison to 300 mg dose of
clopidogrel in the setting of primary PCI was asso-
ciated with lower 30 day mortality (1.9% v. 3.1%; p =
0.03),reinfarction (1.3% v. 2.3%; p = 0.02) and stent
thrombosis(1.7% v. 2.8%; p = 0.04) without an
increase in bleeding .
 Bivalirudin monotherapy however compared to
heparin plus GP IIbIIIa inhibitor was associated with
less bleeding and net adverse clinical event
independent of the higher loading dose of
clopidogrel.

20. THE EFFECT OF SWITCHING FROM HEPARIN
TO BIVALIRUDIN
 Bivalirudin In the Superior Yield of the New Strategy of
Enoxaparin, Revascularization and Glycoprotein IIb/IIIa
Inhibitors (SYNERGY trial), crossover from enoxaparin to
unfractionated heparin or vice versa was associated with
increased risks of bleeding, myocardial infarction and
death .
 Postulated mechanisms for this include under
anticoagulation from switching from one therapy to
another and therefore creating a gap in anticoagulation or
over-anticoagulation from stacking of two antithombin
therapies with prolonged factor antiXa activity without a
sufficient washout period .
 Based on this result, the American College of Cardiology
(ACC), American HeartAssociation (AHA) and the
European Society of Cardiology (ESC) have recommended
consistent antithrombotic therapy from the pre-PCI phase
throughout the PCI itself.

21.  The benefits of reduced bleeding and equivalent
ischaemic protection with bivalirudin however were pre-
served when switching from heparin or enoxaparin plusGP
IIb/IIIa inhibitors to bivalirudin .
 In a substudy from the ACUITY trial, switching from
unfractionated heparin or enoxaparin plus a GP IIb/IIIa
inhibitor to bivalirudin monotherapy resulted in similar
composite ischaemic outcomes [6.9% (bivalirudin) v. 7.4%
(consistent therapy); risk ratio: 0.93; 95% CI: 0.75–1.16; p =
0.52] and a 51% relative reduction in major bleeding
[2.8%(bivalirudin) v. 5.8% (consistent therapy), risk ratio:
0.49,95% CI: 0.36–0.66; p < 0.01] compared with
consistent unfractionated heparin/enoxaparin plus a GP
IIbIIIa inhibitor .
 The crossover from heparin or enoxaparin to bivalirudin at
PCI does not result in an excess of bleeding but has a
protective effect by reducing bleeding by 51%.

22.  This finding has important implications given that many Non-
STEMI-ACS patients are pretreated with heparin or enoxaparin
prior to PCI and given the recommendations from ACC, AHA
and ESC for consistent antithombin therapy from pre PCI to
PCI.
 Heparin is commonly given in the emergency department in the
setting of primary PCI. The HORIZONS-SWITCH Analysis,
which examined the effects of switching from early heparin
given in the emergency department to bivalirudin in patients
undergoing primary PCI for STEMI found lower rates of major
bleeding which translated to lower early and late cardiac
mortality .
 At 30 days, the rate of major bleeding was 7.6% in the
bivalirudin group compared with 12.3% in the continued
heparin plus GP IIb/IIIa inhibitor group (p = 0.0001).
 Cardiac mortality was reduced at 30 days (1.6% v. 2.9%;p = 0.04)
and at two years (2.3% v. 3.8%; p = 0.04).
 The reduced bleeding and cardiac mortality with bivalirudin
were independent of the preprocedure ACT.
 This study suggests that switching from heparin to bivalirudin is
safe and preserves the benefits of bivalirudin in the setting of
primary PCI.

23. THE EFFECT OF BIVALIRUDIN ON SUBGROUPS
 Subgroups Major studies have identified the elderly, females,
renal impairment and anaemia as independent risk factors for
bleeding .
 Independent periprocedural risk factors for major bleeding
include the use of GP IIb/IIIa inhibitors, prolonged time to
sheath removal, prolonged procedure time, access site selection,
right heart catheterisation and use of intra-aortic balloon pump.
 The elderly are at increased risk of both ischaemic and bleeding
events .
 In a substudy from the ACUITY trial, increasing age was
associated with increased ischaemic events and bleeding .
 In patients ≥75years, bivalirudin monotherapy was associated
with comparable ischaemic outcomes (12.2% v. 11%; p = 0.57) but
with less TIMI major bleeding (1.7% v. 3.6%; p < 0.05) compared
to heparin plus GP IIb/IIIa inhibitors.
 The number needed to treat to prevent one major bleed was
lowest in the age group ≥75 (23 to prevent one bleed) and even
lower in the PCI subgroup ≥75 (16 to prevent one bleed).

24.  In a subgroup analysis from the ACUITY trial, females had
comparable 30 day ischaemic outcomes to males (7%v.
8%; p = 0.07) but had significantly increased 30 day rates
of non-CABG major bleeding (8% v. 3%; p < 0.0001) .
 The use of bivalirudin in females resulted in similar 30 day
ischaemic outcomes (7% v. 6%; p = 0.15) with significantly
reduced 30 day major bleeding (5% v. 10%; p < 0.0001) in
comparison to heparin plus GP IIbIIIa inhibitors.
 Renal impairment is associated with an increase in
periprocedural bleeding, ischaemic complications and
target vessel revascularisation .
 Renal impairment in the Global Registry of Acute
Coronary Events (GRACE) registry was associated with a
1.48 fold increase in the risk of bleeding (p = 0.0004)
among 24,045 patients with acute coronary syndromes .
 In a subgroup analysis from the REPLACE 2 trial, renal
impairment (defined as a creatinine clearance ≤60
mL/min) was associated witha 1.72 fold increase in risk of
bleeding (p = 0.028), 1.45 fold increase in ischaemic events
(p = 0.028) and 3.85-fold increase in 12 month mortality (p
< 0.001) .

25.  In a meta-analysis of three randomised trials comparing
bivalirudin with heparin during PCI, bivalirudin was
associated withgreater absolute benefit in reducing
combined bleeding and ischaemic complications with
worsening degrees of renal impairment
 Anaemia is both a predictor of ischaemia and
majorbleeding .
 In a meta-analysis of 39,922 patients in 16 TIMI clinical
trials of acute coronary syndromes, anaemia was noted to
be a major predictor of major cardiovascular events in
both STEMI and Non-STEMI .
 In a subanalysis of the REPLACE 2 trial, major bleeding
was more common in anaemic compared to non-anaemic
patients.(4.9% v. 2.8%; p = 0.0001) . The use of bivalirudin
however in anaemic patients was associated with a lower
risk of major bleeding in comparison to heparin and GP
IIb/IIIainhibitors (3.5% v. 6.2%; p = 0.0221)

26. WHAT THE GUIDELINES SAY
 In its updated 2011 guidelines on the management of NSTEMI-ACS, the ESC
has recommended that the prevention of bleeding should be as important as
the prevention of ischaemia .
 Some of the measures recommended include the choice of safer drugs, titration
of optimal dose of antithrombotic agent (taking into account the patient’s age,
sex and CrCl), reduced duration of antithrombotic agent, avoiding upstream GP
IIbIIIa unless recurrent ischaemia and radial access over femoral access site
 In the updated guidelines of the ESC and CSANZ on the management of Non-
STEMI ACS and recommendations from the Working Group on Thrombosis of
the European Society of Cardiology, antithombotic agents such as bivalirudin
which produce similar anti-ischaemic efficacy while reducing bleeding
complications should be used in preference .
 The CSANZ has further recommended that among patients at high risk of
bleeding during an invasive strategy, bivalirudin should be considered in
preference to heparin or enoxaparin plus GP IIbIIIa inhibitor .
 Amongst patients undergoing primary PCI for STEMI, bivalirudin can be
considered as an alternative to heparin plus GP IIbIIIa inhibitor .
 In the updated2011 ACC/AHA guidelines for Non-STEMI-ACS patients
undergoing PCI who are at high risk of bleeding, the use of bivalirudin is
reasonable

27. CONCLUSION
 Major bleeding carries a mortality hazard
comparable to myocardial infarction and is
associated with significant morbidity, mortality and
hospital costs in patients undergoing PCI for STEMI
and Non-STEMI-ACS.
 Bivalirudin significantly reduces bleeding in low to
high risk Non-STEMI-ACS and primary PCI in STEMI
and provides similar protection to combination
heparin plus GP IIbIIIa inhibitor in reducing
ischaemic events.
 Bivalirudin with its ability to reduce bleeding in PCI
should be considered in patients at high bleeding risk
for PCI, which include STEMI presentations, the
elderly, females, renal impairment and the anaemic.