Anticoagulants are widely used to prevent and treat thrombotic disorders, and continuous advances have refined their efficacy and safety. Beyond their established anticoagulant function, growing evidence indicates that some agents exert additional cardiovascular effects through pleiotropic mechanisms. In this narrative review, we examine both the intended and potential unintended effects of anticoagulants, with particular attention to their actions beyond coagulation. We discuss their influence on vascular pathology and cardiac function, highlighting distinctions between different anticoagulant classes. A deeper understanding of these pleiotropic effects may help guide future research, improve long-term outcomes, and support more targeted therapeutic strategies for patients most likely to benefit.