The conundrum of antithrombotic drugs before, during and after primary PCI

Primary percutaneous coronary intervention (PPCI) has dramatically changed the scenario of ST-segment elevation myocardial infarction, consistently decreasing mortality and morbidity. These goals have been reached thanks to multiple technical and pharmacological refinements. The prevention of ischaemic complications via a combined pharmacoinvasive approach in these patients should concomitantly avoid bleeding events. While the focus in recent years has been on the relevance of bleeding complications, more recent data emphasise the need to optimise pharmacological treatment strategies in the very acute phase of intervention to minimise intraprocedural and early stent-related thrombotic events. The optimal treatment combination, including anticoagulant, oral and parenteral antiplatelet agents remains a matter of ongoing debate. In this paper we review the scientific basis of current era antithrombotic management during PPCI, trying to address some relevant questions, including the timing of initiation of antithrombotics and discussing available treatment options in the light of recent trial results.