Bivalirudin

How it works

It binds directly and reversibly to both the catalytic site and substrate-binding exosite of thrombin, inhibiting fibrin formation and thrombin-mediated platelet activation.

Prescribing in practice

• As with all anticoagulants the principal risk is bleeding, and the dose must be reduced according to renal function because clearance is partly renal.
• It is administered as a bolus and infusion in the catheter-laboratory setting under specialist supervision, with attention to the transition timing to oral antiplatelet/anticoagulant therapy.
• Acute stent thrombosis has been observed in the early hours after primary PCI, so peri-procedural antiplatelet cover and monitoring are important.

Monitoring

Monitor for bleeding, haemoglobin and renal function, with activated clotting time used to guide anticoagulation during the procedure.

Counselling the patient

• Report any bleeding, bruising or signs of recurrent chest pain promptly.
• Renal impairment requires dose adjustment.
• It is an alternative anticoagulant when heparin-induced thrombocytopenia is suspected.

Evidence & guidelines

Bivalirudin during PCI has been evaluated in trials such as HORIZONS-AMI and is an established anticoagulant option in acute coronary syndrome pathways.