Heparin Versus Bivalirudin in ST-segment Elevation Myocardial Infarction

A SCAI-Based National Survey From US Interventional Cardiologists

Harsh Golwala, MD; Sadip Pant, MD; Ambarish Pandey, MD; Michael P. Flaherty, MD, PhD; Glenn A. Hirsch, MD, MHS; Ajay J. Kirtane, MD, SM


J Invasive Cardiol. 2016;28(9):351-356. 

In This Article

Abstract and Introduction


Background. The use of antithrombotic therapy (ATT) (bivalirudin or unfractionated heparin) is a class I recommendation for patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI). This survey was conducted to better understand current United States (US) practices in terms of preferences regarding the selection of ATT in STEMI-PPCI, particularly in light of recent clinical trials.

Methods. An electronic survey consisting of 9 focused questions was forwarded to 2676 US interventional cardiologists who were members of the Society for Cardiovascular Angiography and Interventions (SCAI).

Results. Among 390 responders (14.5%), bivalirudin with bail-out glycoprotein IIb/IIIa inhibitor (GPI) was the predominant strategy for 53% of operators, whereas 32% preferred heparin with bail-out GPI and 15% preferred heparin with more routine GPI. The duration of bivalirudin infusion varied widely among operators, and significant variability existed in the bolus dose of heparin that was preferred by operators. About 49% of respondents stated that the choice of ATT was not affected by the bleeding risk of the patient, although access site did appear to affect the choice of ATT for some operators. Notably, 43% of operators reported to have changed their practice regarding ATT in light of recent trial results.

Conclusion. There is marked variability in self-reported ATT use in STEMI-PPCI among US interventional cardiologists. Given the patient-related variability in bleeding risk and mixed clinical trial results between the two predominant ATT agents, bivalirudin and unfractionated heparin, more data are needed in order to further inform and potentially unify clinical practice in STEMI-PPCI.


The use of antithrombotic agents (ATTs) – typically either bivalirudin or unfractionated heparin – carries a class I recommendation in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI).[1] The recent HEAT-PPCI, EUROMAX, BRIGHT, NAPLES-III, and MATRIX trials, as well as meta-analyses, have provided mixed results in terms of the optimal choice of ATT in STEMI patients undergoing PPCI.[2–12] While the majority of trials have demonstrated bleeding reductions with a bivalirudin-based strategy compared with heparin (especially when heparin is used in conjunction with adjunctive glycoprotein IIb/IIIa inhibitor [GPI]), an increase in acute stent thrombosis has also been observed consistently with bivalirudin monotherapy in the STEMI setting, particularly when bivalirudin is stopped at the end of the PCI.[5]

Given the variability in the clinical trial data as well as polarized responses to these recent data that have been observed,[13] we hypothesized that there would be significant variations in the choice, dosing, and other factors influencing the selection of ATT for STEMI-PPCI among United States (US) interventional cardiologists.