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.