A 65-year-old man presents 90 minutes after onset of anterior STEMI. Primary PCI is available within 30 minutes. He is on warfarin with INR 2.8. The MOST appropriate anticoagulation strategy during primary PCI is:

• A Proceed with PCI; use bivalirudin as procedural anticoagulant ✓
• B Hold PCI until INR < 2.0; administer vitamin K now
• C Proceed with PCI; add additional unfractionated heparin at full dose
• D Administer thrombolytics instead due to anticoagulation risk

Explanation

Primary PCI is the preferred reperfusion strategy and should not be delayed to reverse anticoagulation in STEMI. When therapeutic anticoagulation with warfarin is already present (INR ≥ 2.0), bivalirudin (a direct thrombin inhibitor) is the preferred procedural anticoagulant as it does not require dose adjustment for existing anticoagulation and avoids heparin-related complications. Adding full-dose UFH on top of therapeutic warfarin significantly increases bleeding risk. Thrombolytics are contraindicated with therapeutic anticoagulation.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.