Heparin management in acute myocardial infarction (AMI)

Antithrombotic agents have been shown to be beneficial in the setting of acute coronary syndromes, and as an adjunct to thrombolysis for acute myocardial infarction (AMI). The optimal type and dosing of antithrombotic drug, however, remains elusive. Heparin, the agent most commonly used, has several limitations, the most important of which may be its inability to inhibit clot-bound thrombin. Newer, direct thrombin inhibitors (such as hirudin) provide potent and predictable thrombin inhibition and are able to inhibit clot-bound thrombin. Both heparin and hirudin can carry a substantial risk of haemorrhage, however, and thrombin activity is likely to rebound after discontinuation of either agent. Further, the relationships of antithrombotic/thrombolytic dosing, measures of anticoagulation (such as APTT), and clinical outcomes are not always clear. Nonetheless, from the data available from large, randomised trials, intravenous heparin should remain a standard adjunct to thrombolytic therapy for AMI.