For patients with heparin-induced thrombocytopenia, it is recommended that bivalirudin or argatroban be used to replace UFH.668,669 (Level of Evidence: B) Bivalirudin is being increasingly used in clinical practice670 as evidence emerges from clinical trials across the spectrum of CAD.638 644 In individual trials and meta-analyses, the use of bivalirudin has been associated with reduced bleeding compared with UFH plus a GP IIb/IIIa inhibitor, although concerns about ischemic events have emerged in individual studies.625,637 645 Longer-term follow-up of the major bivali- rudin trials, however, suggests that small or nominal in- creases in ischemic events have not translated into long-term consequences and that treatment at or before the time of PCI with clopidogrel may mitigate any increased early ischemic risk.637 645 Thus, a treatment strategy of bivalirudin compared with heparin (or enoxaparin) plus GP IIb/IIIa inhibitor ap- pears to lower the risk of bleeding complications. The lower bleeding rates associated with bivalirudin (compared with UFH plus a GP IIb/IIIa inhibitor) are mitigated when used concomitantly with a GP IIb/IIIa inhibitor.639 A strategy of use of provisional GP IIb/IIIa inhibitor in patients treated with bivalirudin is widely accepted.639,643,644 In patients with heparin-induced thrombocytopenia,671,672 a direct-thrombin inhibitor (argatroban) has been approved as an alternative parenteral anticoagulant to be used during PCI.668 The use of bivalirudin for heparin-induced thrombo- cytopenia has been reported as well.669 5.7.4.5. Fondaparinux: Recommendation Class III: HARM 1. Fondaparinux should not be used as the sole antico- agulant to support PCI. An additional anticoagulant Table 13. Recommendations for Antiplatelet and Antithrombin Pharmacotherapy at the Time of PCI COR LOE References Relevant Caveats/Comments Oral antiplatelet agents Aspirin I B 301 304,560 563 N/A P2Y12 inhibitors I A 564 568 A loading dose of a P2Y12 inhibitor should be given to patients undergoing PCI with stenting. 