Anticoagulation with bivalirudin during percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) or non-STEMI is associated with similar rates of adverse outcomes to the use of heparin. In the registry-based, open-label VALIDATE-SWEDEHEART trial, 3,005 patients with STEMI and 3,001 patients with non-STEMI were randomly assigned to bivalirudin or heparin during PCI (predominantly radial access). Patients also received a potent P2Y12 inhibitor and were not intended to receive a glycoprotein IIb/IIIa inhibitor. After 180 days, the primary end point (all-cause mortality, myocardial infarction, or major bleeding) occurred in 12.3% and 12.8% of the bivalirudin and heparin groups, respectively. “Even after VALIDATE-SWEDEHEART, there is no definitive answer to the question of whether to use bivalirudin or heparin during PCI,” comments Gregg Stone in an editorial accompanying the trial report, but forthcoming meta-analyses are designed to resolve this question.