Limitations of commonly used anticoagulants, unfractionated heparin, low-molecular-weight heparin, and oral vitamin K antagonists have prompted the development of alternative therapies. Direct thrombin inhibitors are a new class of anticoagulants that bind directly to thrombin and inhibit its interaction with substrates. In this Review, we critically examine the evidence from randomized controlled trials for the efficacy and safety of the parenteral direct thrombin inhibitors bivalirudin and argatroban, and the novel oral direct thrombin inhibitor dabigatran etexilate, in cardiovascular and thrombotic disease.
Bivalirudin is an effective and safer alternative to heparin with or without the addition of a glycoprotein IIb/IIIa inhibitor in patients with acute coronary syndromes or those undergoing percutaneous coronary intervention
Argatroban seems to be a viable treatment for patients with heparin-induced thrombocytopenia, but its role in treating other conditions remains uncertain
Dabigatran is an attractive alternative to low-molecular-weight heparin for the prevention of venous thromboembolism in patients undergoing major orthopedic surgery, and to warfarin for the long-term treatment of venous thromboembolism
The most-compelling indication for dabigatran is as an alternative to warfarin for stroke prevention in patients with atrial fibrillation, where it has been shown to reduce morbidity and mortality
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R. P. Whitlock declares that he is a member of the speakers' bureau of AstraZeneca and Boehringer Ingelheim. In addition, he has received grant or research support from Boehringer Ingelheim. J. W. Eikelboom declares the he is a member of the speakers' bureau and has received grant or research support from each of the following companies: AstraZeneca, Bayer, Boehringer Ingelheim, Bristol–Myers Squibb, Eli Lilly, Johnson & Johnson, Pfizer, and Sanofi. K. A. Arsenault and J. Hirsh declare no competing interests.
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Arsenault, K., Hirsh, J., Whitlock, R. et al. Direct thrombin inhibitors in cardiovascular disease. Nat Rev Cardiol 9, 402–414 (2012). https://doi.org/10.1038/nrcardio.2012.61
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