A minimum threshold activated clotting time (ACT) to guide heparin dosing during percutaneous coronary intervention (PCI) is associated with lower ischemic complications. However, data are variable regarding the risk of high ACT levels. The aim of this study was to assess the impact of peak procedural ACT on complications and mortality for transfemoral and transradial access PCI.

To describe the incidence of bleeding and thrombotic complications in VA-ECMO according to anticoagulation strategy.

Utilization of cangrelor following coronary artery stent placement as a bridge to cardiac surgery has been previously described in the literature. However, the use of cangrelor as bridge therapy to cardiac surgery for endovascular revascularization is lacking. We describe a case involving a 47-year-old female who developed a left lower extremity tibioperoneal trunk non-obstructing arterial dissection following extracorporeal membrane oxygenation decannulation, requiring repair with a Viabahn endoprosthesis. To maintain stent patency, as well as treat the patient's multi-vessel coronary disease and left ventricular thrombus, triple therapy with cangrelor, aspirin, and bivalirudin was utilized as the patient was optimized for a coronary artery bypass procedure. Our case describes a unique antiplatelet and anticoagulation strategy in a complex patient involving a multi-disciplinary team.

Acute coronary syndrome (ACS) is one of the most common leading global causes of mortality, encompassing ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). Percutaneous coronary intervention (PCI) has become a pivotal therapeutic approach for ACS, underscoring the importance of anticoagulation strategies. Among the commonly employed anticoagulants in PCI, heparin and bivalirudin take precedence, with heparin serving as the archetypal choice. Nevertheless, the determination of an optimal anticoagulation regimen remains a point of contention in contemporary clinical practice. To address the differences in anticoagulants during PCI, we meticulously conducted a literature review through PubMed and Web of Science, employing search terms such as "heparin," "bivalirudin," "percutaneous coronary intervention," and "acute coronary syndrome." For patients with PIC brought on by STEMI, NSTEMI, and stable or UA pectoris, the review focused on randomized controlled trials to assess and compare the efficacy and safety of heparin and bivalirudin as anticoagulant options. This systematic review is aimed at furnishing valuable insights into the ongoing debate surrounding the choice of anticoagulation regimens in PCI. By scrutinizing clinical evidence derived from relevant trials, we seek to inform and guide healthcare practitioners in making informed decisions based on the unique requirements of patients with various ACS presentations.

Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction with significant thromboembolic risk. Though there are models for use of non-heparin anticoagulants, heparin remains the preferred anticoagulant in many operative settings, especially cardiovascular surgery and percutaneous cardiac intervention. The natural history of HIT can be stereotyped into phases using HIT laboratory testing to guide clinical management and determine whether heparin re-exposure can be considered. In acute HIT and subacute HIT A (immunoassay positive, functional assay positive) when thromboembolic risk is high, non-urgent procedures should be delayed, if feasible. If procedures cannot be delayed, approaches include intraoperative bivalirudin or intraoperative heparin with pre- or intra-operative plasma exchange or a potent antiplatelet agent, sometimes in combination with intravenous immunoglobulin. In subacute HIT B (immunoassay positive, functional assay negative) and remote HIT (immunoassay negative, functional assay negative), brief exposure to heparin in the intraoperative setting with close monitoring post-operatively is suggested due to the low risk of recurrent HIT.

In clinical practice, the dose of bivalirudin may not be fully applicable to the Chinese population. Therefore, this study aimed to explore the efficacy and safety of a reduced dose (80% of the recommended dose) of bivalirudin without post-procedure infusion for 3-4 h in patients with acute coronary syndrome (ACS) undergoing elective percutaneous coronary intervention (PCI).

To compare the short-and medium-term ischemia and bleeding risk between unfractionated heparin and bivalirudin in patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI). A total of 742 patients with ACS who underwent emergency PCI in Xinxiang Central Hospital of Henan Province from January 2016 to June 2022 were selected and divided into unfractionated heparin group (385 cases) and bivalirudin group (357 cases) according to the anticoagulant regimen. All patients were followed up for 6 months. The incidence of ischemic and bleeding events at 30 days and 6 months after operation were compared between the two groups. Multivariate Cox proportional regression model was used to analyze the risk factors of ischemic and bleeding events in the two groups. Kaplan Meier method was used to calculate the cumulative survival rate, and log rank method was used to analyze the difference in survival rates. The age of 742 patients was (62.5±14.8) years old, and male accounted for 58.5% (434 cases). The age of unfractionated heparin group was (61.8±14.8) years old, and male accounted for 59.2% (228 cases); The age of bivalirudin group was (63.3±14.8) years old, and male accounted for 57.7% (206 cases). The incidence of bleeding events at 30 days and 6 months in the unfractionated heparin group were 6.8% (26 cases) and 9.9% (38 cases), respectively, which were higher than 3.4% (12 cases) and 4.5% (16 cases) in the bivalirudin group (all 0.05); The incidence of ischemic events at 30 days and 6 months in the unfractionated heparin group were 7.5% (29 cases) and 11.2% (43 cases), respectively, which were not observed to be significantly different with those in the bivalirudin group [6.2% (22 cases) and 9.5% (34 cases)] (all 0.05). Compared with patients using bivalirudin, the value (95%) of bleeding events after emergency PCI in patients using unfractionated heparin was 1.964 (1.317-3.125) (0.05), and the value (95%) of ischemic events was 0.948(0.595-1.510) (0.05). The cumulative incidence of bleeding events was 9.9% in unfractionated heparin group and 4.5% in bivalirudin group (=0.005); The cumulative incidence of ischemic events was 11.2% in unfractionated heparin group and 9.5% in bivalirudin group (=0.459). The incidence of short-term hemorrhage events in ACS patients treated with bivalirudin anticoagulation after emergency PCI is lower than that of unfractonated heparin, which can reduce the risk of short-term hemorrhage.

The term heparin resistance is likely best defined as the failure of an appropriate dose of unfractionated heparin (UFH) to achieve a predetermined level of anticoagulation. Unfortunately, and despite many prior reports, there is no established consensus as to what either the appropriate dose or the predetermined level should be. Traditionally, assays used to monitor anticoagulation with UFH have been clot based, including the activated partial thromboplastin time, used for patients on the ward or intensive care unit, and the activated clotting time, used for patients undergoing vascular interventions and cardiopulmonary bypass. Unfortunately, these tests may be highly influenced by other factors occurring in many patients, especially those with inflammation or acute infection, as noted during the COVID-19 pandemic. Many hospitals have thus moved to anti-Xa testing for heparin monitoring. Another important factor in defining heparin resistance includes dosing, whether weight-based or total daily dosing is used, as initial reports of heparin resistance described daily doses independent of body weight. Multiple causes of apparent heparin resistance include hypercoagulability, antithrombin deficiency, andexanet alfa used for direct oral anticoagulant reversal, thrombocytosis, and antiphospholipid antibody syndromes. Treatment options for managing patients with heparin resistance include weight-based dosing and administration of additional UFH, antithrombin supplementation, or the use of an alternative anticoagulant such as the direct thrombin inhibitors bivalirudin or argatroban.

To analyze the effects on coagulation function and safety of bivalirudin and heparin in patients undergoing percutaneous coronary intervention (PCI) and provide clinical evidence for their application.