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Intracoronary Bivalirudin Bolus in ST-Elevation Myocardial Infarction Patients Treated with Primary Angioplasty: Theoretical Bases, Clinical Experience, and Future Applications

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Abstract

Intracoronary thrombus is a common finding in acute coronary syndromes and often correlates with adverse prognosis and complications during percutaneous coronary interventions (PCIs). Bivalirudin, a direct thrombin inhibitor, is one of the recommended antithrombotic treatments for PCI in ST-elevation myocardial infarction (STEMI). The intracoronary administration of a bivalirudin loading dose, even if off-label, offers theoretical advantages over the standard intravenous route, providing a very high drug concentration in the infarct-related artery without increasing the total dose of the drug administered. After the description in case reports of such an approach, a larger scale experience was recently reported in a large cohort of patients with STEMI treated during primary PCI with a bivalirudin intracoronary loading dose followed by the standard intravenous maintenance infusion. As a control group, a propensity score-matched cohort of patients undergoing primary PCI treated with intravenous bivalirudin in the same institution was selected. Compared with the intravenous bolus, the intracoronary administration of bivalirudin was associated with improved ST-segment resolution, lower post-procedural peak CK-MB levels, and better Thrombolysis in Myocardial Infarction (TIMI) frame count values, without difference in bleeding rates. Thus, this new promising antithrombotic strategy, based on the intracoronary administration of a bivalirudin loading dose during primary PCI, appeared safe, improved myocardial reperfusion, and mitigated enzymatic myocardial infarct size compared with the standard intravenous protocol. Randomized trials are warranted to confirm these results and evaluate the possible long-term clinical benefits.

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Authors and Affiliations

  1. Cardiologia II, AOU Maggiore della Carità, C.so Mazzini 18, 28100, Novara, Italy

    Alessandro Lupi, Alon Schaffer, Andrea Rognoni & Angelo S. Bongo

  2. Cardiology Division, ASL VCO, Domodossola, Italy

    Alessandro Lupi

  3. Cardiology Division, Ospedale S. Andrea, Vercelli, Italy

    Chiara Cavallino

  4. Cardiology Division, A.O. Fatebenefratelli, Milan, Italy

    Bernardo Cortese

  5. Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA

    Allan S. Jaffe

  6. University of Florida, College of Medicine, Jacksonville, Jacksonville, FL, USA

    Dominick J. Angiolillo

  7. Institute of Cardiology, UCSC, Rome, Italy

    Italo Porto

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  1. Alessandro Lupi
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  2. Alon Schaffer
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  3. Andrea Rognoni
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  4. Chiara Cavallino
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Correspondence to Alessandro Lupi.

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Alessandro Lupi, Alon Schaffer, Andrea Rognoni, Chiara Cavallino, Angelo Bongo, Bernardo Cortese, Allan Jaffe, Dominick Angiolillo and Italo Porto have no conflicts of interest relevant to the content of this article.

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Lupi, A., Schaffer, A., Rognoni, A. et al. Intracoronary Bivalirudin Bolus in ST-Elevation Myocardial Infarction Patients Treated with Primary Angioplasty: Theoretical Bases, Clinical Experience, and Future Applications. Am J Cardiovasc Drugs 16, 391–397 (2016). https://doi.org/10.1007/s40256-016-0186-z

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