Immediate primary percutaneous coronary intervention (PCI), in patients presenting with acute myocardial infarction has played a great role in reducing mortality and morbidity in this group of patients [ ]. In these and other patients undergoing invasive coronary procedures, there has been a constant effort to maximize myocardial salvage and minimize bleeding risks. These strategies include use of more potent oral and intravenous anti-platelet agents to maintain optimal reperfusion [ , ], or use of radial access [ ] to reduce access related bleeding events. While unfractionated heparin (UFH), remains the most commonly used anticoagulant during PCI, bivalirudin (BIVAL), emerged as an alternative to primarily reduce bleeding risks owing to its more predictable pharmacodynamics [ ]. While several randomized controlled PCI trials have been performed comparing BIVAL to UFH, the results from these trials have been inconsistent. To answer these uncertainties, Al-Abdouh et al, in this issue of the Cardiovascular Revascularization Medicine , analyzed the differential effect of BIVAL vs. UFH in patients with acute myocardial infraction undergoing PCI [ ].