Is bivalirudin ready for a comeback? Pros and cons

Bivalirudin, a direct thrombin inhibitor, has been extensively studied as an alternative option for anticoagulation in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI). Studies comparing bivalirudin to heparin yielded mixed results, with signals of concern about acute stent thrombosis; in addition, the perceived lower bleeding risk associated with bivalirudin has been attributed to the increased use of glycoprotein IIb/ IIIa inhibitors (GPI) in heparin arms, suggesting potential bias in the comparison. Nevertheless, more recent trials and meta-analyses showed that bivalirudin was associated with similar or even lower risks of death and ischaemic events – including stent thrombosis – as well as less bleeding compared to heparin. In the light of accumulating evidence, whether bivalirudin should be considered as the preferred option for anticoagulation in ACS patients undergoing PCI is an area of ongoing debate.