Parenteral anticoagulation strategies for non-ST elevation acute coronary syndrome (NSTE-ACS) during percutaneous coronary intervention (PCI) must balance ischemic prevention against bleeding risks. Intravenous unfractionated heparin remains the standard of care with a Class 1 recommendation. While bivalirudin and enoxaparin serve as alternatives, bivalirudin is assigned a Class 2b recommendation due to concerns regarding acute stent thrombosis unless followed by a post-procedural full-dose infusion. Dr. Binita Shah, an interventional cardiologist and 2025 ACS Guidelines Writing Committee member, explains that historical data favoring bivalirudin were likely confounded by the routine use of GP IIb/IIIa inhibitors with heparin. Conversely, Fondaparinux is contraindicated as a standalone agent for PCI (Class 3: Harm) because the OASIS-5 and OASIS-6 trials demonstrated significantly higher rates of catheter-related thrombosis. Consequently, Fondaparinux is discouraged even in conservatively managed patients who may eventually require invasive intervention.
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