Oral direct thrombin inhibition: a double-edged sword?

New oral anticoagulants have been shown to be not inferior to vitamin K antagonists in reducing thrombo-embolic events in patients with non-valvular atrial fibrillation and venous thrombo-embolism. However, those among them whichdirectly inhibit thrombin have been associated with greater risk of myocardial infarction. In this article we review the pleiotropic physiological effects of thrombin and their potential link with the observed greater incidence of myocardial infarction during therapy with oral direct thrombin inhibitors. On this basis, we believe that further studies are necessary to clear out doubts on the use of these drugs in the general population and, more specifically, in patients with coronary artery disease. For these reasons, in our opinion at present it may be prudent to especially caution high risk patients initiating therapy with a direct thrombin inhibitor (or those who are already taking it) about this possible risk. For patients with established coronary artery disease an alternative oral anticoagulant may be at present a better choice.