SYSTEMATIC REVIEW
Efficacy and safety of bivalirudin and heparin with or without glycoprotein IIb/IIIa inhibitors in patients of acute coronary syndrome undergoing percutaneous coronary intervention: a systematic review and network meta-analysis
1
Department of Medicine, Gujranwala Medical College, Gujranwala, Pakistan
2
Department of Internal Medicine, Hospital Corporation of America (HCA), Houston Kingwood/University of Houston College of Medicine, Houston, USA
3
Department of Hospital Medicine, Guthrie Medical Group, Cortland, NY, USA
4
Wah Medical College, Pakistan
5
Department of Medicine, Springfield Regional Center, Springfield, OH, USA
6
Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
7
Augusta University Cardiology Center, Augusta, Georgia, USA
8
Ascension St. Thomas Hospital, University of Tennessee, Nashville, TN, USA
9
Wayne State University, Detroit Medical Center, Cardiovascular Institute, Detroit, MI, USA
Submission date: 2025-09-22
Final revision date: 2026-01-18
Acceptance date: 2026-04-12
Publication date: 2026-06-19
Corresponding author
M Chadi Alraies
Wayne State University Detroit Medical Center Cardiovascular Institute Heart Hospital 311 Mack Ave Detroit, MI 48201, USA Phone: (216) 255-0008
Wayne State University Detroit Medical Center Cardiovascular Institute Heart Hospital 311 Mack Ave Detroit, MI 48201, USA Phone: (216) 255-0008
Arch Med Sci Atheroscler Dis 2026;11(1):87-101
KEYWORDS
TOPICS
ABSTRACT
Introduction:
Recent clinical trials have revealed that bivalirudin has comparable efficacy to heparin. In this network meta-analysis, we aimed to compare the efficacy and safety of bivalirudin and heparin administered as monotherapy or with glycoprotein IIb/IIIa inhibitors, in patients of acute coronary syndromes undergoing percutaneous coronary intervention (PCI).
Material and methods:
We performed a systematic search of PubMed and Embase to identify studies with acute coronary syndrome patients > 18 years, who underwent PCI, and were treated with bivalirudin or heparin either as monotherapy or with glycoprotein IIb/IIIa inhibitors. Outcomes were major bleeding, major adverse cardiovascular events (MACE), all-cause mortality, reinfarction, stent thrombosis and cardiovascular death. Pooled relative risks (RR) were calculated using the net-meta module with/and random effects model with a 95% confidence interval (CI) for statistical significance. Higgins I2 statistic was used to assess heterogeneity.
Results:
A total of 23 randomized controlled trials comprising 72,628 patients were included. Bivalirudin monotherapy compared to heparin monotherapy demonstrated no significant difference in risk of bleeding (RR = 0.83, 95% CI: 0.64–1.08, p = 0.17), MACE (RR = 0.99, 95% CI: 0.93–1.05, p = 0.72) and other outcomes. Bivalirudin combined with GP IIb/IIIa inhibitors had an increased risk of stent thrombosis compared with heparin monotherapy (RR = 3.62, 95% CI: 1.002–13.14). In major bleeding, heparin with GP IIb/IIIa inhibitors had a statistically significant RR of 1.454 (95% CI: 1.006–2.1009, p = 0.045).
Conclusions:
Bivalirudin and heparin have similar efficacy and safety profiles in patients undergoing PCI for ACS. The choice of the anticoagulant should be individualized based on patient and procedural characteristics.
Recent clinical trials have revealed that bivalirudin has comparable efficacy to heparin. In this network meta-analysis, we aimed to compare the efficacy and safety of bivalirudin and heparin administered as monotherapy or with glycoprotein IIb/IIIa inhibitors, in patients of acute coronary syndromes undergoing percutaneous coronary intervention (PCI).
Material and methods:
We performed a systematic search of PubMed and Embase to identify studies with acute coronary syndrome patients > 18 years, who underwent PCI, and were treated with bivalirudin or heparin either as monotherapy or with glycoprotein IIb/IIIa inhibitors. Outcomes were major bleeding, major adverse cardiovascular events (MACE), all-cause mortality, reinfarction, stent thrombosis and cardiovascular death. Pooled relative risks (RR) were calculated using the net-meta module with/and random effects model with a 95% confidence interval (CI) for statistical significance. Higgins I2 statistic was used to assess heterogeneity.
Results:
A total of 23 randomized controlled trials comprising 72,628 patients were included. Bivalirudin monotherapy compared to heparin monotherapy demonstrated no significant difference in risk of bleeding (RR = 0.83, 95% CI: 0.64–1.08, p = 0.17), MACE (RR = 0.99, 95% CI: 0.93–1.05, p = 0.72) and other outcomes. Bivalirudin combined with GP IIb/IIIa inhibitors had an increased risk of stent thrombosis compared with heparin monotherapy (RR = 3.62, 95% CI: 1.002–13.14). In major bleeding, heparin with GP IIb/IIIa inhibitors had a statistically significant RR of 1.454 (95% CI: 1.006–2.1009, p = 0.045).
Conclusions:
Bivalirudin and heparin have similar efficacy and safety profiles in patients undergoing PCI for ACS. The choice of the anticoagulant should be individualized based on patient and procedural characteristics.
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