Anticoagulation in the management of ST-segment elevation myocardial infarction

Patients with ST-segment elevation myocardial infarction (STEMI) require immediate reperfusion therapy in order to salvage ischemic myocardial tissue and reduce mortality. Reperfusion therapy can be provided mechanically with primary percutaneous coronary intervention (PCI), or pharmacologically with fibrinolysis. Regardless of the reperfusion strategy selected, the appropriate use of anticoagulant therapy is critical to its success. There have been a number of clinical trials evaluating the different anticoagulants in patients with STEMI, as well as recent updates to the guidelines for management of patients with STEMI and on the use of PCI. When making clinical decisions on the use of anticoagulant therapy in the management of patients with STEMI, it is important to not only understand the contents of these consensus guidelines but to also have an appreciation of the details of the clinical trials that have evaluated the different anticoagulants. In this review, the reader will find an evaluation of the current guidelines concerning the use of anticoagulant therapy in patients with STEMI as well as a detailed examination of the literature with critical analysis on issues that should be considered when deciding on the appropriate implementation of anticoagulant therapy in patients with STEMI undergoing either mechanical or pharmacologic reperfusion.