Bivalirudin is a unique anticoagulant with a number of already approved and several new potential applications. There is now extensive experience in patients with unstable angina undergoing PTCA, and it has recently received approval by the FDA for PCI in patients with HIT. Data are also accumulating on using bivalirudin for HIT, especially in the critically ill patient with multiorgan failure. It is also being used as an alternative anticoagulant in patients undergoing PTA in the peripheral arteries, including the carotid and renal and in the lower extremities.

Bivalirudin may emerge as the favored alternative anticoagulant to heparin in the setting of cardiac surgery, in patients both with and without HIT (Warkentin and Greinacher, 2003; Dyke et al., 2006; Smedira et al., 2006). Its short half-life, unique metabolism, and means of elimination (enzymic) and low immunogenicity provide it with distinct advantages over heparin and the other DTIs. In addition, its reversible thrombin inhibition may be associated with decreased bleeding risk. Finally, although there are no antidotes available, the potential for reversibility with hemofiltration (which can be used routinely in the postcardiac surgery setting) adds to its attractiveness.

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