B to B
All patients with ST-elevation myocardial infarction should be treated with anticoagulant therapy, which should be given as soon as possible after diagnosis. The choice of anticoagulant agent depends upon the treatment strategy for each patient. The dosing and duration for these drugs (unfractionated heparin [UFH], low molecular weight heparin, bivalirudin, or fondaparinux) are presented above.
●For patients treated with primary percutaneous coronary intervention (PCI), we recommend anticoagulant therapy (Grade 1B).
•We suggest UFH in preference to bivalirudin (Grade 2B). This recommendation assumes that patients will receive a potent oral antiplatelet agent (ticagrelor or prasugrel), which we prefer to clopidogrel. For those patients who receive clopidogrel, either heparin or bivalirudin is a reasonable choice. In addition, patients at high bleeding risk are reasonable candidates for bivalirudin.
●For patients treated with fibrinolytic therapy, we suggest anticoagulant therapy (Grade 2B).
•For patients not at high risk of bleeding, we suggest using enoxaparin as opposed to UFH, fondaparinux, or bivalirudin (Grade 2C). For those patients in whom PCI is possible or likely after fibrinolytic therapy, UFH is a reasonable choice.
•For patients at high risk of a bleeding complication and who are not likely to require PCI, we suggest fondaparinux as opposed to enoxaparin or UFH (Grade 2C).
●For patients treated without reperfusion, we suggest anticoagulant therapy with enoxaparin or UFH as opposed to no anticoagulant therapy, as soon as possible after presentation (Grade 2B). We do not use fondaparinux or bivalirudin in this setting.