Hirudin in Acute Coronary Syndromes: When Cents Override Good Sense.

Two large multicenter clinical trials comparing heparin with hirudin in the management of patients with acute coronary syndromes have recently been completed. Direct thrombin inhibition was reported to result in only a modest reduction in the incidence of primary endpoint in GUSTO IIb, and to be of no demonstrable benefit in TIMI 9b. However, closer examination of the performance of hirudin in these trials suggests it to have been harshly judged. Hirudin provided a consistently more reliable anticoagulant effect than heparin, was associated with a comparable risk of bleeding and minimal risk of allergy. Furthermore, direct thrombin inhibition was more effective in preventing events in patients with unstable angina and non-Q wave infarction, and resulted in a significant reduction in the incidence of reinfarction among all facets of the acute coronary syndromes. There was in addition a striking benefit of combining hirudin with streptokinase in patients with acute myocardial infarction. Based on these data, there is little doubt that hirudin rather than heparin should form the foundation on which to base future strategies for management of the acute coronary syndromes.