Antithrombotic therapy plays a pivotal part in invasively managed patients with acute coronary syndrome, particularly in those who require percutaneous coronary intervention. In this setting, the radial artery has become the preferred vascular access site given the reduced risk of bleeding and mortality compared with femoral access. Although bivalirudin and unfractionated heparin with optional glycoprotein IIb/IIIa inhibitor use are both recommended for patients with acute coronary syndrome undergoing percutaneous coronary intervention, which of these is the most optimal treatment remains largely debated. In fact, although bivalirudin has been associated with reduced bleeding, albeit of varying magnitude depending on the prevalence of glycoprotein IIb/IIIa inhibitor use and unfractionated heparin dose in the comparator arms, its effect on ischaemic events is controversial, particularly in light of the early hazard of stent thrombosis.
Angiolillo DJ. Lancet 2018;392:801–2.