title: Intracoronary Bivalirudin Bolus in ST-Elevation Myocardial Infarction Patients Treated with Primary Angioplasty: Theoretical Bases, Clinical Experience, and Future Applications.
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.
authors.affiliation: Cardiologia II, AOU Maggiore della Carità, C.so Mazzini 18, 28100, Novara, Italy. lupialessandro1@gmail.com.|Cardiology Division, ASL VCO, Domodossola, Italy. lupialessandro1@gmail.com.
authors.forename: Alessandro
authors.identifier: http://orcid.org/0000-0003-3644-0449
authors.initials: A
authors.lastname: Lupi
authors.affiliation: Cardiologia II, AOU Maggiore della Carità, C.so Mazzini 18, 28100, Novara, Italy.
authors.forename: Alon
authors.initials: A
authors.lastname: Schaffer
authors.affiliation: Cardiologia II, AOU Maggiore della Carità, C.so Mazzini 18, 28100, Novara, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Rognoni
authors.affiliation: Cardiology Division, Ospedale S. Andrea, Vercelli, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Cavallino
authors.affiliation: Cardiologia II, AOU Maggiore della Carità, C.so Mazzini 18, 28100, Novara, Italy.
authors.forename: Angelo S
authors.initials: AS
authors.lastname: Bongo
authors.affiliation: Cardiology Division, A.O. Fatebenefratelli, Milan, Italy.
authors.forename: Bernardo
authors.initials: B
authors.lastname: Cortese
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
authors.forename: Allan S
authors.initials: AS
authors.lastname: Jaffe
authors.affiliation: University of Florida, College of Medicine, Jacksonville, Jacksonville, FL, USA.
authors.forename: Dominick J
authors.initials: DJ
authors.lastname: Angiolillo
authors.affiliation: Institute of Cardiology, UCSC, Rome, Italy.
authors.forename: Italo
authors.initials: I
authors.lastname: Porto
mesh_terms: D015906:Angioplasty, Balloon, Coronary / Q000379:methods; D000925:Anticoagulants / Q000008:administration & dosage; D000991:Antithrombins / Q000008:administration & dosage*; D004562:Electrocardiography / Q000379:methods; D006470:Hemorrhage / Q000188:drug therapy; D006629:Hirudins / Q000008:administration & dosage*; D006801:Humans; D007275:Injections, Intravenous / Q000379:methods; D009203:Myocardial Infarction / Q000188:drug therapy*; D015425:Myocardial Reperfusion / Q000379:methods; D010446:Peptide Fragments / Q000008:administration & dosage*; D062645:Percutaneous Coronary Intervention / Q000379:methods; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D011994:Recombinant Proteins / Q000008:administration & dosage; D013927:Thrombosis / Q000188:drug therapy
chemical_list: D000925:Anticoagulants; D000991:Antithrombins; D006629:Hirudins; D010446:Peptide Fragments; D010975:Platelet Aggregation Inhibitors; D011994:Recombinant Proteins; C074619:bivalirudin