Introduction: Together with antiplatelet therapy, anticoagulants are vital to improve outcomes in patients presenting with ST-segment elevation myocardial infarction. Challenges lie in finding the optimal balance between the risk of bleeding and preventing thrombotic complications such as reinfarction or stent thrombosis. During the last decade, bivalirudin was introduced as a valid alternative to heparin for patients undergoing primary percutaneous coronary intervention. Several trials have been conducted to identify the agent with the best antithrombotic results at the lowest bleeding complication rate. In a rapidly evolving field with changes in vascular access, available P2Y12 inhibitors, and indications for glycoprotein IIb/IIIa inhibitor administration, conflicting evidence became available. Areas covered: This paper mainly focuses on the evidence above and gives brief discussion to the recent literature on anticoagulation in fibrinolytic therapy and advances in antiplatelet therapy. Expert opinion: To date, no robust evidence is available challenging unfractionated heparin as the primary choice for anticoagulation in patients presenting with ST-segment elevation myocardial infarction. Further research should include efforts to refine anticoagulation strategies on an individual patient level. For patients undergoing primary percutaneous coronary intervention, bivalirudin could be used as an alternative to unfractionated heparin, while enoxaparin or fondaparinux is an alternative agent for patients treated with fibrinolytic therapy.

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Expert Opinion on Pharmacotherapy
Department of Cardiology

van Gameren, M., Lemmert, M., Wilschut, J.M. (J. M.), Daemen, J., de Jaegere, P., Zijlstra, F., … Diletti, R. (2018). An update on the use of anticoagulant therapy in ST-segment elevation myocardial infarction. Expert Opinion on Pharmacotherapy (Vol. 19, pp. 1441–1450). doi:10.1080/14656566.2018.1512583