Direct thrombin inhibitors for non-ST–segment elevation acute coronary syndromes: what, when, and where?

Background Unfractionated heparin has been the cornerstone of antithrombin therapy in the treatment of non-ST–segment elevation acute coronary syndromes for more than a decade. Several new anticoagulants have emerged in recent years and have been studied extensively in patients with unstable coronary syndromes and in the percutaneous coronary intervention setting. Methods Direct thrombin inhibitors comprise a family of agents with promising properties that offer several potential advantages over unfractionated heparin. Hirudin has been studied in patients with ST-elevation myocardial infarction, non-ST–elevation coronary syndromes, and coronary angioplasty. Bivalirudin has been studied in patients undergoing percutaneous coronary revascularization, with very promising efficacy and safety profile compared with unfractionated heparin. Results The clinical trials of direct thrombin inhibitors in non-ST–elevation acute coronary syndromes and coronary angioplasty are reviewed.