Anticoagulant for primary percutaneous coronary intervention - the last dance for unfractionated heparin?

MOTS CLES Infarctus myocarde ; Anticoagulation ; Heparine ; Heparine de bas poids moleculaire ; Bivalirudine Rates of shortand long-term mortality after an acute coronary syndrome (ACS) have been reduced dramatically through advances in percutaneous coronary intervention (PCI) techniques and the availability of new antithrombotic agents. This is particularly true for patients with ST-elevation myocardial infarction (STEMI) treated with primary PCI. On the antiplatelet side, we have, besides clopidogrel, two new P2Y12 inhibitors — prasugrel and ticagrelor — for which data and subset analyses have allowed a better understanding of which patients with an ACS would truly benefit from these drugs. On the anticoagulant side, besides unfractionated heparin (UFH), we have three newer anticoagulants that can be used in ACS: enoxaparin, fondaparinux and bivalirudin. In this competitive field, the past decade has provided a large flow of evidence-based information in terms of the safety and efficacy of these antithrombotic agents. This information needs to be implemented both in guidelines and in our daily clinical practice. As always, there is no simple rule or conclusion; rather, different options exist according to current practice and our own personal environment and experiences. The efficacy of anticoagulation therapy is evaluated on the basis of ischaemic complications of ACS and sometimes the outcome of PCI itself, both of which have a real impact on shortand long-term mortality. The first goal of anticoagulation therapy during primary PCI of STEMI is therefore to avoid or control at all times the development of thrombus and in doing so obtain or maintain blood flow through the coronary circulation and protect the myocardium from harmful damage related to ischaemia and necrosis. If the drug efficacy translates into a mortality reduction, there is a good chance of recognition and acceptation of the new treatment by practising physicians.