Managing coronary thrombus is a challenging task and requires adequate knowledge of the various antithrombotic
agents available. In this article, we will briefly analyze the risk-benefit profile of antithrombotic agents, with critical
analysis of the scientific evidence available to support their use. Since thrombus consists of platelets and coagulation cofactors,
an effective antithrombotic strategy involves using one anticoagulant with two or more antiplatelet agents.
Unfractionated heparin traditionally has been the most commonly used anticoagulant but is fast being replaced by relatively
newer agents like LMWH, direct thrombin inhibitors, and Factor Xa inhibitors.
In recent years, the antiplatelet landscape has changed significantly with the availability of more potent and rapidly acting
agents, like prasugrel and ticagrelor. These agents have demonstrated a sizeable reduction in ischemic outcomes in patients
with ACS, who are treated invasively or otherwise, with some concern for an increased bleeding risk. Glycoprotein
IIb/IIIa inhibitors have an established role in high risk NSTE ACS patients pretreated with dual antiplatelets, but its role in
STEMI patients, treated with invasive approach and dual antiplatelets, has not been supported consistently across the studies.
Additionally, in recent years, its place as a directly injected therapy into coronaries has been looked into with mixed
results. In conclusion, a well-tailored antithrombotic strategy requires taking into account each patient’s individual risk
factors and clinical presentation, with an effort to strike balance between not only preventing ischemic outcomes but also
reducing bleeding complications.