Tailored antithrombotic therapy for acute coronary syndromes

Acute coronary syndromes usually result from thrombotic occlusion of a coronary artery at the site of atherosclerotic plaque disruption. The mainstay of treatment is the use of antiplatelet and antithrombotic therapy to maintain patency of the artery. In patients with non-ST segment elevation acute coronary syndromes, antithrombotic therapy followed by coronary revascularization (when feasible in patients with high-risk features) is the optimal management strategy. In the patient with ST elevation acute coronary syndromes who receives a fibrinolytic agent antithrombotic agents, are also important to prevent reocclusion. Bleeding complications of antithrombotic therapy are associated with a substantial increase in adverse short- and long-term outcomes. Hence, the selection of the most appropriate antithrombotic agent aims to minimize both ischemic and hemorrhagic complications. Factors that are associated with increased bleeding risk and need to be considered when selecting an antithrombotic agent include decreased renal function, short time to invasive procedure (<24 h), and the overall bleeding risk. For patients who will undergo later cardiac catheterization and are not at high bleeding risk, either enoxaparin or fondaparinux are acceptable choices. For patients who are likely to undergo early catheterization or have an increased bleeding risk, either fondaparinux or unfractionated heparin are the optimal choice. Patients with severe impairment of renal function should receive unfractionated heparin.