Time-dependent effects of unfractionated heparin in patients with ST-elevation myocardial infarction transferred for primary angioplasty

Upstream anticoagulation: Another brick in the wall?

“…Through this nonrandomized analysis of a large STEMI population, Cantor and colleagues have tried to clarify a topic not clearly addressed in the guidelines, object of conflicting studies. Consistent with Giralt et al, 4 their findings support the use of upstream anticoagulation in primary PCI with significant advantages in terms of patency of IRA and thrombotic burden. STEMI patients have a marked thrombotic burden, an important risk factor for mortality, and, in the age‐old question between bleeding and ischemic risk, early anticoagulation, in addition to having an important effect on thrombotic burden, is also associated with a lower rate of minor bleeding and a lower major bleeding trend.…”

“…Despite everything, there is still no clear consensus regarding the optimal drug and timing of the anticoagulation therapy in primary PCI, with a high variability between centers regarding the beginning before or during the procedure 3 . The upstream anticoagulation treatment although has shown an increased risk of bleeding and a delay in treatment, it is frequently used because it has also demonstrated to improve flow in pre‐PCI infarct‐related artery (IRA) and to improve the clinical outcome 4 …”

Upstream anticoagulation for patients with ST‐elevation myocardial infarction undergoing primary percutaneous coronary intervention: Insights from the TOTAL trial

“…Two nonrandomized studies showed that earlier administration of heparin was associated with higher IRA patency rates and lower mortality with no increase in bleeding. 1,2 The HEAP (Heparin in Early Patency) trial randomized 584 STEMI patients undergoing primary PCI to high-dose heparin (300 IU/kg) versus low-dose heparin (0 or 5,000 IU). 3 The STEMI guidelines do not address the timing of anticoagulation.…”

“…However, the optimal timing of anticoagulant administration remains uncertain. Upstream early administration of anticoagulation prior to the PCI procedure has been shown to improve the pre-PCI flow in the infarct-related artery (IRA) in some studies, 1,2 which may lead to reduced infarct size and improved clinical outcomes. However, upstream anticoagulation may increase bleeding and may delay transfer to the catheterization laboratory.…”

“…However, upstream anticoagulation may increase bleeding and may delay transfer to the catheterization laboratory. Previous smaller studies evaluating upstream anticoagulation for primary PCI have yielded conflicting results [1][2][3] and guidelines do not provide specific recommendations on the timing of anticoagulation for primary PCI. 4,5 Accordingly, in clinical practice there is significant variability in terms of whether anticoagulation is commenced prior to or during the PCI procedure.…”