Current and Future Options for Anticoagulant Therapy in the Acute Management of ACS.

OPINION STATEMENT: Anticoagulation with a parenteral (intravenous or subcutaneous) antithrombin agent is foundational to the early management of acute coronary syndrome (ACS). While indications for, the timing of, and the choice among agents (other than aspirin) that provide antiplatelet effects are all subject to discussion, the need for acute anticoagulation is beyond question. There are a number of agents that can be used for anticoagulation in ACS, depending upon the intended near-term management of the patient (medical vs interventional), the patient's ischemic risk, and the patient's hemorrhagic risk. It is usually appropriate for therapy to be initiated in the emergency department (ED), which in turn supports close collaboration between "upstream" providers and interventional cardiologists. Clinical trial data suggest that "switching" agents during ACS care affords no efficacy advantage and may increase bleeding risk. At least 1 potential new agent (otamixaban) that can be used in all ACS care settings is on the near-term horizon, with the drug currently in late Phase III testing.