Bivalirudin in Percutaneous Coronary Interventions and Acute Coronary Syndromes: New Concepts, New Directions

Inhibition of thrombin and platelets during percutaneous coronary intervention (PCI), using a combination of unfractionated heparin and aspirin, is designed primarily to minimize the rare but devastating potential acute thrombotic complications of the procedure. Direct thrombin inhibitors, such as bivalirudin (formerly Hirulog, The Medicines Company, Cambridge, MA), offer specific theoretic advantages over unfractionated heparin as antithrombin therapy. This review focuses on the pharmacologic promise and the clinical performance of bivalirudin in PCI, and in the pharmacologic management of acute coronary syndromes. Clinical experience with bivalirudin in PCI preceded recent dramatic advances in mechanical interventional techniques and the emergence of novel potent platelet inhibitors. The role of bivalirudin and other direct thrombin inhibitors in the modern era of coronary intervention therefore requires further elucidation.