1. Applications of bivalirudin in interventional cardiology
Giuseppe Biondi Zoccai
Divisione di Cardiologia
Università di Torino
Ospedale S. Giovanni Battista di Torino

2. LEARNING GOALS SCOPE OF THE PROBLEM TREATMENT ALTERNATIVES
POTENTIAL CLINICAL USES
Heparin-induced thrombocytopenia
Ischemic cardiomyopathy
Chronic stable angina
Non-ST-elevation acute coronary syndromes
ST-elevation acute coronary syndromes
Transcatheter aortic valve implantation

3. SCOPE OF THE PROBLEM Impact of MI and major bleeding in the first
30 days on 1-year mortality in ACUITY
Major Bleed only (without MI) (N=551)
12.5%
28.9%
Both MI and Major Bleed (N=94)
3.4%
No MI or Major Bleed (N=12,557)
MI only (without Major Bleed) (N=611)
8.6%

4. LEARNING GOALS SCOPE OF THE PROBLEM TREATMENT ALTERNATIVES
POTENTIAL CLINICAL USES
Heparin-induced thrombocytopenia
Ischemic cardiomyopathy
Chronic stable angina
Non-ST-elevation acute coronary syndromes
ST-elevation acute coronary syndromes
Transcatheter aortic valve implantation

5. TREATMENT ALTERNATIVES
Coagulation
cascade
Platelet
cascade
Tissue factor
Collagen
Aspirin
Clopidogrel
Prasugrel
Ticagrelor
GPIIb/IIIa
inhibitors
Plasma clotting
cascade
ADP
Thromboxane A2
Prothrombin AT
Bivalirudin
Hirudin
Argatroban
LMWH
Heparin
Thrombo-
lytics
Factor Xa
Conformational activation of GPIIb/IIIa AT
Thrombin
Platelet aggregation
Fibrinogen
Fibrin
Thrombus

6. TREATMENT ALTERNATIVES
Age
Renal function
Elderly: ???
Normal: Enox, Bival, Fonda, UFH
CKD: Bival, UFH
Bleeding Risk
Cost
Low: Enox, UFH, Bival
Mod: Bival, Fonda, UFH
High: Bival, Fonda, UFH
Enox, UFH
Fonda, Bival?
Ease of use
Ischemic Risk
Enox, Bival, Fonda
Low: Enox, Bival, UFH
Mod: Enox, Bival, UFH
High: Enox, Fonda, Bival
PCI vs CABG vs Med Rx
Time to Cath
PCI: Enox, Bival, UFH
CABG: UFH
Med Rx: Enox, Fonda, Bival
Rapid: Bival, UFH
Early: Enox, UFH, Bival
Delayed: Enox

7. LEARNING GOALS SCOPE OF THE PROBLEM TREATMENT ALTERNATIVES
POTENTIAL CLINICAL USES
Heparin-induced thrombocytopenia
Ischemic cardiomyopathy
Chronic stable angina
Non-ST-elevation acute coronary syndromes
ST-elevation acute coronary syndromes
Transcatheter aortic valve implantation

8. 47-YEAR-OLD WOMAN WITH UNSTABLE ANGINA AND HIT
What is the most appropriate antithrombotic regimen for PCI in patients with HIT?

9. HEPARIN-INDUCED THROMBOCYTOPENIA
The Anticoagulant Therapy with Bivalirudin to Assist in the performance of PCI in patients with heparin-induced Thrombocytopenia (ATBAT) trial

10. LEARNING GOALS SCOPE OF THE PROBLEM TREATMENT ALTERNATIVES
POTENTIAL CLINICAL USES
Heparin-induced thrombocytopenia
Ischemic cardiomyopathy
Chronic stable angina
Non-ST-elevation acute coronary syndromes
ST-elevation acute coronary syndromes
Transcatheter aortic valve implantation

11. 69-YEAR-OLD MAN WITH CSA, SEVERE LVD, PRIOR CABG AND PRIOR STROKE
What is the most appropriate antithrombotic regimen for ischemic cardiomyopathy or CSA?

12. ISCHEMIC CARDIOMYOPATHY OR CHRONIC STABLE ANGINA
Kastrati et al, New Engl J Med 2008

13. ISCHEMIC CARDIOMYOPATHY OR CHRONIC STABLE ANGINA
Kastrati et al, New Engl J Med 2008

14. LEARNING GOALS SCOPE OF THE PROBLEM TREATMENT ALTERNATIVES
POTENTIAL CLINICAL USES
Heparin-induced thrombocytopenia
Ischemic cardiomyopathy
Chronic stable angina
Non-ST-elevation acute coronary syndromes
ST-elevation acute coronary syndromes
Transcatheter aortic valve implantation

15. 71-YEAR-OLD WOMAN WITH NSTEMI AND CHRONIC RENAL FAILURE
What is the most appropriate antithrombotic regimen for NSTEACS?

16. 1-month rate of major adverse cardiac events in the ACUITY trial
NSTEACS
1-month rate of major adverse cardiac events in the ACUITY trial

17. 1-month rate of net clinical adverse events in the ACUITY trial
NSTEACS
1-month rate of net clinical adverse events in the ACUITY trial

18. LEARNING GOALS SCOPE OF THE PROBLEM TREATMENT ALTERNATIVES
POTENTIAL CLINICAL USES
Heparin-induced thrombocytopenia
Ischemic cardiomyopathy
Chronic stable angina
Non-ST-elevation acute coronary syndromes
ST-elevation acute coronary syndromes
Transcatheter aortic valve implantation

19. 76-YEAR-OLD WOMAN WITH ST-ELEVATION ACS AND CARDIOGENIC SHOCK
What is the most appropriate antithrombotic regimen for STEMI?

20. ST-ELEVATION ACS
Mehran et al, Lancet 2009

21. ST-ELEVATION ACS
Mehran et al, Lancet 2009

22. ST-ELEVATION ACS
Mehran et al, Lancet 2009

23. LEARNING GOALS SCOPE OF THE PROBLEM TREATMENT ALTERNATIVES
POTENTIAL CLINICAL USES
Heparin-induced thrombocytopenia
Ischemic cardiomyopathy
Chronic stable angina
Non-ST-elevation acute coronary syndromes
ST-elevation acute coronary syndromes
Transcatheter aortic valve implantation

24. 87-YEAR-OLD MAN WITH SEVERE AORTIC STENOSIS AND PROHIBITIVE STS SCORE
What is the most appropriate antithrombotic regimen during TAVI?

25. TAKE HOME MESSAGES
The interventional cardiologist is challenged every day by the quest for an optimal balance between preventing bleeding and thrombosis
Several alternative parenteral antithrombotic drugs are available, with a significantly different efficacy and safety profile
Bivalirudin may represent an effective and safe alternative in several clinical settings, especially when there is moderate or high risk for bleeding

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