Comparison of bivalirudin versus heparin in percutaneous coronary intervention for patients with acute coronary syndrome

Background: Bivalirudin and heparin are commonly employed anticoagulants in percutaneous coronary intervention (PCI) for patients diagnosed with acute coronary syndrome (ACS). This meta-analysis aimed to compare the safety and efficacy of bivalirudin and heparin in patients with ACS undergoing PCI. Methods: We systematically searched PubMed, Embase, Web of Science, and the Cochrane Library for randomized controlled trials (RCTs) and cohort studies comparing bivalirudin with heparin in patients with ACS undergoing PCI. The outcomes included all-cause mortality, cardiovascular mortality, major bleeding, major adverse cardiovascular events (MACEs), net adverse clinical events, myocardial infarction (MI), stent thrombosis (ST), and stroke. Results: This study included 11 RCTs and 17 cohort studies, encompassing 584,249 patients. Among in-hospital outcomes, bivalirudin was found to significantly reduce the incidence of all-cause mortality (relative risk [RR] = 0.86, 95% confidence interval [CI]: 0.84–0.88, P < .001, I 2 = 0%) and major bleeding (RR = 0.74, 95% CI: 0.62–0.88, P < .001, I 2 = 51%) compared with heparin, while there were no significant differences in MACEs, MI, ST, and stroke. Among 30-day follow-up outcomes, bivalirudin was found to significantly reduce the incidence of all-cause mortality (RR = 0.85, 95% CI: 0.76–0.95, P = .006, I 2 = 24%), cardiovascular mortality (RR = 0.81, 95% CI: 0.70–0.94, P = .004, I 2 = 1%), major bleeding (RR = 0.59, 95% CI: 0.49–0.72, P < .001, I 2 = 67%), and net adverse clinical events (RR = 0.79, 95% CI: 0.70–0.89, P < .001, I 2 = 55%) compared with heparin, while there were no significant differences in MACEs, MI, ST, and stroke. Conclusion: This meta-analysis suggests that bivalirudin may offer advantages over heparin in reducing in-hospital and 30-day mortality and major bleeding in patients with ACS undergoing PCI, with no significant differences in ischemic outcomes such as MACEs, MI, ST, or stroke. These findings suggest that bivalirudin may be a reasonable alternative to heparin in selected patients, but more large-scale, long-term RCTs are needed to confirm these results.