Bivalirudin versus heparin in percutaneous coronary intervention—a systematic review and meta-analysis of randomized trials stratified by adjunctive glycoprotein IIb/IIIa strategy

Heparin has traditionally been the anticoagulant of choice for percutaneous coronary intervention (PCI). The addition of glycoprotein IIb/IIIa inhibitors (GPIs) to heparin in early trials led to a decrease in ischemic complications, but at the expense of an increase in major bleeding (1-3). Subsequently numerous studies have compared bivalirudin, a direct thrombin inhibitor, with the combination of heparin and GPIs. These trials demonstrated a reduction in major bleeding and more stent thrombosis with bivalirudin compared to heparin, but it is unclear if this is related to the confounding effect of GPI use in the heparin arm. More contemporary trials have aimed to compare bivalirudin to heparin with either no planned GPI use (4-12) or matched GPI use in both arms (8,13-16) but results have been mixed. Therefore, we performed a systematic review and meta-analysis of all randomized controlled clinical trials comparing bivalirudin and heparin, stratified by GPI use strategy