Journal of Invasive Cardiology

In the event that primary coronary intervention becomes necessary due to a large infarct and an unstable patient, a short-acting anticoagulant with predictable pharmacokinetics and less demonstrable major bleeding complications might be the “ideal” agent. Bivalirudin, a direct thrombin inhibitor, has been shown to be more effective and with less major bleeding complications than unfractionated heparin during percutaneous coronary interventions.^1–3 Furthermore, its anticoagulant effect is predictable and has a short half-life in patients with normal renal function. The choice of bivalirudin over heparin following surgical intervention is theoretically advantageous when there is a need for systemic anticoagulation. One disadvantage of bivalirudin, however, would be the inability to reverse its anticoagulation process if this becomes necessary. This disadvantage, however, is at least partially offset by the very short half-life of the drug. Patients with recent surgical procedures and strokes have been traditionally excluded from interventional trials using bivalirudin and, therefore, safety data of bivalirudin in these patients is not available. In this case report, the interventional outcome was successful and bivalirudin proved to be a successful choice. Further data, however, is needed to clarify the safety of bivalirudin immediately postoperatively and particularly in the neurosurgical patient.

Finally, treatment of the culprit vessel alone (right coronary artery) and staging treatment of the left circumflex artery would have been a likely preferred approach in the management of this patient. The treatment of a non-culprit vessel in the setting of an AMI has been traditionally discouraged. Cessation of all antiplatelets and anticoagulants would have become necessary if intracerebral bleeding occurred during or following the intervention. The presence of several stented vessels would have increased the risk of acute thrombosis and further complicated the management of this patient. Avoiding stenting or using a heparin-bonded stent (Hepacoat) instead of a bare metal stent for the occluded right coronary artery would have been my preferred approach during this intervention. This would have reduced the need for clopidogrel-aspirin combination that caries a higher risk of bleeding than aspirin alone⁴ and allowed safely the sole use of aspirin post procedure.