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Bivalirudin in the treatment of acute coronary syndrome

BMJ 2016; 352 doi: (Published 18 January 2016) Cite this as: BMJ 2016;352:i86
  1. Stephen P Hoole, consultant cardiologist,
  2. Nick E J West, consultant cardiologist
  1. 1Papworth Hospital, Papworth Everard, Cambridge CB23 3RE, UK
  1. Correspondence to: S P Hoole s.hoole{at}

Is beginning to look like expensive dilute heparin

Bivalirudin was heralded as the successor to heparin. It is a direct thrombin inhibitor with a more predictable dose response than heparin, a short half life of 22 minutes, and the ability to bind circulating and clot bound thrombin. But does it have genuine advantages over heparin in patients having percutaneous coronary interventions (PCI) for acute coronary syndrome or is it just expensive dilute heparin?

Bivalirudin is the market leader among anticoagulants used in PCIs in the United States and is endorsed with class I recommendations by national society guidelines.1 2 Global market revenues are estimated to be worth billions of dollars, with bivalirudin costs in the UK ranging from £300 (€400; $440) to £1000 per patient episode, depending on duration of infusion. By comparison, heparin costs only a few pounds.

Bivalirudin was established as the anticoagulant of choice in PCI during an era when glycoprotein IIb IIIa inhibitors were often coadministered with heparin. When compared with this combination, large trials such as HORIZONS-AMI, ACUITY, and EUROMAX confirmed that patients treated with …

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