What is the best anticoagulant therapy during primary percutaneous coronary intervention for acute myocardial infarction?

Abstract

Both ST-segment elevation myocardial infarction and percutaneous coronary intervention (PCI) are associated with a highly prothrombotic state, and thrombin plays a critical role during occlusive clot generation and subsequent occurrence of an ischemic event. Therefore, a strategy of anticoagulation plus dual antiplatelet therapy has been regarded as de facto standard therapy during primary PCI (pPCI). Recently, there has been great controversy surrounding the role of bivalirudin versus unfractionated heparin in pPCI. Earlier, the results of the HORIZONS-AMI trial, particularly those regarding the long-lasting mortality benefit, provided a strong rationale for recommending bivalirudin therapy in pPCI. However, the mortality benefit of bivalirudin observed in HORIZONS-AMI has not been repeated in more contemporary studies or demonstrated in recent meta-analyses. The current report will provide a concise review of the controversy surrounding the optimal anticoagulant therapy for pPCI. Recent evidence suggests that unfractionated heparin deserves strong reconsideration despite the reports of pharmacologic weaknesses, particularly when used with a strategy of selective glycoprotein IIb/IIIa therapy, and it appears that a strategy of bivalirudin therapy in pPCI should be reserved for patients at high bleeding risk.

A systematic review on the role of bivalirudin in patients undergoing percutaneous coronary interventions: primus inter pares or a falling star?

“…Following its binding to bivalirudin, thrombin cleaves the Pro-Arg bond within the amino terminal of bivalirudin allowing the recovery of thrombin activity. Bivalirudin has a plasma half-life of 25 minutes after its intravenous administration and only 20% of the given dose is cleared through kidneys [3,[11][12][13]. According to the experiments performed by Butenas et al [14], increasing concentrations of bivalirudin prolong the initiation phase of thrombin generation in a concentration-dependent manner.…”

“…In this setting, interventional treatment, when compared with conservative strategy, prevents recurrent episodes of coronary ischemia and in intermediate-to high-risk patients is associated with improved survival and lower risk of MI. PCI procedures effectively restore patency of culprit coronary arteries and improve myocardial perfusion [3]. Importantly, PCI interventions are performed in a highly thrombogenic environment.…”

Antithrombotic management in patients with percutaneous coronary intervention requiring oral anticoagulation

“…The dynamic evolution of therapeutic options including the use of vitamin K antagonists (VKA), NOAC, more potent antiplatelet drugs as well as new generation drug-eluting stents (DES) could lead to the view that the current recommendations on the management in this group of patients do not keep up with the recent advances of modern pharmaco-invasive medicine [1, 5–7]. In the present overview, we summarize the current status of antithrombotic management in AF patients undergoing PCI for stable CAD or ACS.…”