Heparin in a patient with MI on anticoagulation

Should heparin be administered in a patient with myocardial infarction (MI) who is already on long-term oral anticoagulants?

Zaza Iakobishvili, MD, PhD: According to the ST-segment elevation myocardial infarction (STEMI) guidelines there is a clear answer but in real life it is a very tough question, because when you approach a patient on oral anticoagulation you do not know exactly if they missed the last dose, if they took the right dose, or what kind of anticoagulation they are taking.

Guidelines are clear in terms of doing primary percutaneous coronary intervention (PCI) always with the support of parenteral anticoagulation. Heparin will be given in all cases but in a very controlled setting, with ACT, or activated clotting time. It will guide us to prevent unneeded bleeding complications in this situation.

After the primary PCI you can manage your patients according to their real needs, because you will probably have this exact regimen and the level of anticoagulation and it is easier afterwards. But in the immediate time frame when you diagnose STEMI, anticoagulation must be given, even if the patient is supposed to be on chronic anticoagulation.