Appropriate Use of Bivalirudin in Catheterization Procedures

Background: Bivalirudin, a direct thrombin inhibitor, is an intravenous anticoagulant indicated in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Bivalirudin has been shown to reduce major and minor bleeding while resulting in similar or decreased rates of ischemia after PCI when used instead of heparin plus glycoprotein IIb/IIIa inhibitors. Bivalrudin involves a set IV bolus dose, followed by a continuous infusion that must be dose adjusted for renal impairment. Methods: This was a retrospective chart review including patients aged 18 years and older that received bivalirudin as part of a catheterization procedure at St. Vincent Hospital in Indianapolis between January 2011 and December 2012. The patients\u27 electronic medical records were reviewed to collect demographic data, renal function, indication, dosing, and concomitant use of antiplatelet agents. Renal impairment warranting dose reductions for the bivalirudin infusion was defined as an estimated creatinine clearance less than 30 mL/minute calculated using the patient\u27s actual body weight in the Cockcroft-Gault equation. Results: Fifty adult patients with an average age of 64.2 years were assessed, including 27 (54%) males and 23 females. Eight (16%) patients were not dosed according to protocol for the set IV bolus dose, of which 6 differed from the recommended dose by ±5%. For the continuous infusion, 16 (32%) patients were not dosed according to protocol, of which 7 differed from the recommended rate by ±5%. Of the 39 patients with measured pre- and post-PCI hemoglobin and/or hematocrit labs, 2 (5.1%) experienced major bleeding defined as a decrease in hemaglobin level of 4 g/dL or more without an overt bleeding source. Conclusions: The findings of this study helped identify targets for improving the use of bivalirudin in catheterization procedures, namely improving adherence to the bivalirudin dosing protocol. Although two patients experienced a significant drop in hemoglobin of greater than 4 g/dL, no clinically significant bleeding events were noted