ClinCalc Pro
Menu
Calculators Drugs Pathways AI Dx Donate Get the App
Direct Thrombin Inhibitor / PCI Pregnancy: Use only if clearly indicated — limited data; short-term procedural use

Bivalirudin (PCI Anticoagulation)

Brand names: Angiox

Adult dose

Dose: Primary PCI (STEMI): 0.75 mg/kg IV bolus immediately before PCI, then 1.75 mg/kg/hour infusion during procedure (continue for up to 4 hours post-PCI).
Route: Intravenous bolus then infusion
Frequency: Bolus at start of PCI then infusion during and after
Max: Per weight-based calculation
Direct thrombin inhibitor — bivalirudin binds and inhibits both free and clot-bound thrombin. Alternative to UFH in PCI, particularly for patients with HIT or at high bleeding risk. No antidote — reversal is spontaneous (short half-life 25 minutes).

Paediatric dose

Route: IV
Seek specialist opinion — not licensed in children

Dose adjustments

Renal

eGFR 30-59: reduce infusion to 1.4 mg/kg/hour. eGFR 10-29: reduce to 1 mg/kg/hour. ESRD on dialysis: reduce to 0.25 mg/kg/hour.

Hepatic

No dose adjustment required

Clinical pearls

  • HORIZONS-AMI trial (Stone et al. NEJM 2008): bivalirudin vs UFH + GP IIb/IIIa inhibitor in primary PCI for STEMI — 40% reduction in major bleeding; reduction in 30-day mortality. Established bivalirudin as alternative to heparin + GP IIb/IIIa inhibitor in STEMI PCI.
  • HIT use: bivalirudin is a first-line anticoagulant in patients with confirmed or suspected HIT requiring cardiac catheterisation — heparin is absolutely contraindicated in HIT.
  • No antidote: bivalirudin has a short half-life (25 minutes in normal renal function). Anticoagulant effect disappears rapidly on stopping infusion. In bleeding — stop infusion; effect wanes within 1-2 hours. Unlike heparin, no protamine reversal.
  • Renal adjustment critical: bivalirudin is renally cleared; half-life extends dramatically in renal impairment (up to 3.5 hours in dialysis). ACT monitoring recommended in severe CKD.
  • Acute stent thrombosis signal: early post-PCI period (first 4 hours) showed slightly higher stent thrombosis with bivalirudin vs heparin in some trials. Extended post-PCI infusion (1.75 mg/kg/h for 4 hours post-PCI) mitigates this risk.

Contraindications

  • Active bleeding
  • Severe uncontrolled hypertension
  • Bacterial endocarditis
  • Hypersensitivity to bivalirudin

Side effects

  • Bleeding (lower major bleeding vs UFH in some trials)
  • Acute stent thrombosis (slight increase vs UFH in early HORIZONS-AMI data — mitigated by post-PCI infusion)
  • Thrombocytopenia (rare — unlike HIT with heparin)
  • Back pain (during infusion)

Interactions

  • Antiplatelet drugs — additive bleeding risk
  • Warfarin/DOACs — additive; avoid concurrent use unless specifically indicated

Monitoring

  • ACT (activated clotting time — during PCI)
  • Haemoglobin/haematocrit (post-procedure)
  • Signs of bleeding
  • eGFR (dose adjustment)

Reference: BNFc; BNF 90; HORIZONS-AMI Trial (Stone et al. NEJM 2008); ESC STEMI 2023; NICE NG185; SPC Angiox. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

Calculators
Pathways