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data for its use in conjunction with ticagrelor or prasugrel treatment are limited. Due to its proven efficacy in preventing intra-procedural and post-procedural stent thrombosis in P2Y12 receptor inhibitor-naïve patients, cangrelor may be considered on a case-by-case basis in P2Y12 receptor inhibitor-naïve ACS patients undergoing PCI, including in patients for whom it may not be feasible to give oral drugs in the setting of emergent PCI (e.g. CS patients and/or patients on mechanical ventilation).

6.2 Anticoagulant treatment in the acute

phase Anticoagulation is an important component of the initial treatment of ACS and of the peri-procedural treatment for ACS patients managed with an invasive strategy. Therefore, parenteral anticoagulation is recommended for all ACS patients at the time of diagnosis.255 Table 6 provides an overview of the relevant anticoagulant drugs and their dosing in ACS patients. In general, a crossover between anticoagulants should be avoided in patients with ACS (especially between unfractionated heparin [UFH] and low-molecular-weight heparin [LMWH]), with the exception of adding UFH to fondaparinux when a patient presenting with NSTE-ACS proceeds to PCI after a period of fondaparinux treatment (see below for further detail).256,257 Anticoagulants should generally be discontinued immediately after PCI, except in specific clinical settings such as the confirmed presence of LV aneurysm with thrombus formation or AF requiring anticoagulation. In addition, for bivalirudin in patients with STEMI undergoing PCI, a full dose post-PCI infusion is recommended. In this section of the guideline, we summarize the recommendations for anticoagulant treatment in the acute phase for patients with STEMI undergoing PPCI and for patients with NSTE-ACS undergoing angiography (and PCI if indicated).

6.2.1 Anticoagulation in patients with ST-elevation

myocardial infarction undergoing primary percutaneous coronary intervention Unfractionated heparin has been established as the standard of care in patients with STEMI undergoing PPCI due to its favourable risk/benefit profile. In these patients, anticoagulation should be given during the invasive procedure. High-quality evidence with respect to the benefit of administering anticoagulation at an earlier time point in patients undergoing a PPCI strategy is lacking. Alternatives to UFH that should be considered in patients with STEMI undergoing PPCI include enoxaparin (a LMWH) and bivalirudin (a direct thrombin inhibitor). The ATOLL (STEMI Treated With Primary Angioplasty and Intravenous Lovenox or Unfractionated Heparin) trial reported a reduction in the primary endpoint at 30 days (incidence of death, complication of MI, procedure failure, or major bleeding) with enoxaparin in comparison to UFH in patients with STEMI undergoing PPCI.258 In the BivaliRudin with prolonged full-dose Infusion durinG primary PCI versus Heparin Trial 4 (BRIGHT-4), 6016 patients with STEMI undergoing PPCI were randomized to either bivalirudin (with a full dose post-PCI infusion) or UFH.259 The use of GP IIb/IIIa inhibitors was restricted to patients who experienced thrombotic complications. The primary endpoint (a composite of all-cause mortality or Bleeding Academic Research Consortium [BARC] type 3–5 bleeding at 30 days), the individual components of the primary endpoint, and definite or probable stent thrombosis were all significantly reduced in the bivalirudin group.259 Based on the totality of the available data, bivalirudin with a full-dose post-PCI infusion should be considered as an alternative to UFH, although further studies to confirm these findings in non-East Asian populations are required. Bivalirudin is also the recommended alternative to UFH in patients presenting with ACS who have a history of heparin-induced thrombocytopaenia. Additional information about bivalirudin, including evidence tables summarizing the relevant clinical trials, is provided in the Supplementary data online.

Based on the results of the OASIS-6 (The Safety and Efficacy of Fondaparinux Versus Control Therapy in Patients With ST Segment Elevation Acute Myocardial Infarction) trial, fondaparinux is not recommended in patients with STEMI undergoing PPCI.260 To summarize, parenteral anticoagulation is recommended for patients with STEMI undergoing PPCI and UFH is the default choice of anticoagulant at present. Enoxaparin and bivalirudin should be considered as alternatives to UFH in these patients but fondaparinux is not recommended.

6.2.2 Anticoagulation in patients with

non-ST-elevation acute coronary syndrome undergoing angiography and percutaneous coronary intervention if indicated Patients with NSTE-ACS are also recommended to receive parenteral anticoagulation. In patients with NSTE-ACS who are anticipated to undergo immediate or early (i.e. <24 h from the time of diagnosis) invasive angiography and PCI if indicated, parenteral anticoagulation at the time of diagnosis is recommended, and UFH has been historically established as the anticoagulant of choice. However, in a meta-analysis of trials comparing UFH with enoxaparin, mortality and major bleeding was not different between both agents in patients with NSTE-ACS or stable patients scheduled for PCI.261 Therefore, enoxaparin should be considered as an alternative to UFH in these patients (especially in cases where monitoring of clotting times is complex). NSTE-ACS patients who do not undergo early invasive angiography (i.e. within 24 h of diagnosis) will have an extended initial treatment phase consisting of only pharmacological treatment. In these patients, fondaparinux therapy is recommended in preference to enoxaparin while awaiting invasive angiography, based on the favourable outcomes demonstrated with fondaparinux in comparison to enoxaparin in the Fifth Organization to Assess Strategies in Acute Ischemic Syndromes (OASIS-5) trial.262 Of note, guiding catheter thrombus formation was of concern with fondaparinux and, therefore, a full-dose bolus of UFH should be given if the patient proceeds to PCI. The potential impact of contemporary changes in clinical practice (including radial access, early catheterization, and infrequent GP IIb/IIIa inhibitor therapy) on the treatment effect observed in OASIS-5 should also be considered. If fondaparinux is not available, enoxaparin should be considered for these patients. Intravenous enoxaparin should also be considered as an anticoagulant for PCI in patients with NSTE-ACS in whom subcutaneous (s.c.) enoxaparin was used while awaiting coronary angiography.261 In summary, parenteral anticoagulation is recommended for patients with NSTE-ACS. For patients with NSTE-ACS undergoing immediate or early angiography (± PCI if indicated), UFH is recommended but enoxaparin should be considered as an alternative to UFH. For patients with NSTE-ACS who are not anticipated to undergo early angiography, fondaparinux (with a UFH bolus at time of PCI) is recommended in preference to enoxaparin, although enoxaparin should be considered if fondaparinux is not available. Downloaded from academic.oup.com/eurheartj/article/44/38/3720/7243210 by guest on 07 October 2026