Cardiovascular & blood

Bivalirudin

A direct thrombin inhibitor peptide used as the anticoagulant during coronary stenting, including in heparin allergy.

Strong evidenceApproved drugAdd to compare

What it is

Bivalirudin is a synthetic 20-amino-acid analogue of hirudin, the anticoagulant in leech saliva. It blocks thrombin directly rather than through antithrombin, which means it also works on clot-bound thrombin and does not cause the antibody problems seen with heparin. It is a hospital medicine given by infusion during percutaneous coronary intervention.

How it works

1
Binds the active site and exosite I of thrombin, blocking fibrin formation.
2
Inhibits both free and clot-bound thrombin, unlike heparin.
3
Its effect is reversible because thrombin slowly cleaves the peptide, so clotting recovers within about an hour of stopping.
4
Does not require antithrombin, so it works when antithrombin is low.
5
No risk of heparin-induced thrombocytopenia or the associated antibodies.

What it's studied for

Anticoagulation during percutaneous coronary intervention

Patients with heparin-induced thrombocytopenia

Acute coronary syndrome managed invasively

Comparisons against heparin plus glycoprotein IIb/IIIa inhibitors

Reported and studied effects

Similar or lower rates of major bleeding than heparin plus a glycoprotein IIb/IIIa inhibitor in PCI trials
Comparable ischaemic outcomes at 30 days
Rapid loss of anticoagulant effect after stopping the infusion
A higher rate of stent thrombosis in one large trial when bailout glycoprotein inhibitors were withheld

Research protocol notes

Research context only

Research context only - a hospital anticoagulant. In the PCI trials the regimen was a 0.75 mg per kilogram intravenous bolus followed by an infusion of 1.75 mg per kilogram per hour for the duration of the procedure; trials measured major bleeding and major adverse cardiac events at 30 days and one year.

These figures are described so you can understand what researchers did. They are not a dose, a schedule, or a suggestion — and they are not a substitute for a doctor.

Possible side effects and contraindications

Safety profile

Possible side effects

Bleeding, including major and access-site bleeding
Hypotension
Back pain
Nausea
Rare allergic reactions
Stent thrombosis if anticoagulation is inadequate

Contraindications and cautions

Active major bleeding
Prior hypersensitivity
Severe uncontrolled hypertension
Not for intramuscular injection
Kidney impairment requires dose adjustment

A side-effect list is never complete, and these are not the only situations that warrant caution. Anything unexpected, or anything you are unsure about, should be discussed with a doctor before use.

Evidence assessment

Strong evidenceReplicated, large human trials

Replicated, large human trials

Several large randomised trials in PCI, including REPLACE-2, HORIZONS-AMI and VALIDATE-SWEDEHEART, with bleeding and ischaemic endpoints.

References

References link to published literature, regulator pages or literature indexes. Where a link points to a search, it collects the peer-reviewed work on that molecule rather than a single study.

Compare Bivalirudin with another peptide →

Related peptides

Other entries in Cardiovascular & blood.

All Cardiovascular & blood peptides →

Cardiovascular & blood

Eptifibatide

A cyclic peptide platelet blocker used during angioplasty and in acute coronary syndromes.

Strong evidenceApproved drug

Cardiovascular & blood

Nesiritide

Recombinant human BNP, licensed in the US for acute decompensated heart failure, with neutral symptom benefit in large trials.

Moderate evidenceApproved drug