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Successful treatment of STEMI requires early diagnosis and urgent passivation of the culprit lesion by antithrombotic therapy and mechanical revascularisation. A delicate balance exists between the risk of thrombosis and bleeding, consequently the choice of antithrombotic therapy is critical. Bivalirudin, a direct thrombin inhibitor, has been shown to offer a superior safety profile over heparin and GP2b3a inhibition in STEMI (Horizons-AMI). Similarly, the novel P2Y12-receptor inhibitor, Prasugrel, achieves faster and more consistent platelet inhibition than clopidogrel with improved clinical outcomes in STEMI (TRITON-TIMI 38). Although untested in a randomised clinical trial, the combination of bivalirudin and prasugrel for the treatment of STEMI appears to offer fast and effective inhibition of thrombosis with an acceptable bleeding profile. A randomised trial is in progress (BRAVE 4) but data will not be …