Lecture 31 Combining Antiplatelets and Anticoagulants

Question 1

What are factors that increase the risk of bleeding, both major and minor?

Answer 1

Major: eGFR <30, cirrhosis with portal HTN, active malignancy, spontaneous bleeding requiring hospitalization or transfusion, chronic bleeding, Hgb <110, platelets <100 x 10^9/L, spontaneous ICH or traumatic ICH <1 year ago or stroke <6 months ago, long term anticoagulation, major surgery/trauma in last 30 days, non-deferrable major surgery

Minor: eGFR 30-59, spontaneous bleeding not meeting major criteria, Hgb 110-129 (men) or 110-119 (women), any ischemic stroke not meeting major, long term oral NSAID or steroid, >75 years old

Question 2

When might DAPT shortening be indicated?

Answer 2

consider shortening for high bleed risk pt

3-6 months, could consider 1 month in very high bleed risk or if urgent surgery, SAPT with ASA or P2Y12 inhibitor thereafter

Question 3

When might DAPT lengthening be indicated?

Answer 3

for ACS pt who haven’t had a bleeding event at 1 year ⇒ consider extension up to 3 years

for elective pt with no bleeding events at 6 months ⇒ consider extending up to 3 years

Question 4

What is the antiplatelet/anticoagulant regimen for someone who has both a PCI + AF?

Answer 4

AF Patients with Coronary or Vascular Disease and an Indication for OAC (Age >/= 65 or CHADS2 >/= 1): if Elective PCI without high risk features for thrombotic CV events ⇒ Dual Tx = OAC + Clopidogrel for 1-12 months post PCI ⇒ then just OAC after for Stable CAD/PAD

if ACS with PCI OR elective PCI with high risk features for thrombotic CV events ⇒ Triple Tx = OAC + ASA + Clopidogrel for 1 day to 1 month ⇒ then Dual Tx = OAC + Clopidogrel for up to 12 months post PCI ⇒ then just OAC for Stable CAD/PAD

if ACS without PCI ⇒ Dual Tx = OAC + Clopidogrel for 1-12 months post PCI ⇒ then OAC for Stable CAD/PAD

Question 5

What did the WOEST trial look at?

Answer 5

compared dual and triple antithrombotic treatment bleed rates (warfarin + clopidogrel versus warfarin + clopidogrel + ASA)

dual tx showed an NNT of 4 for lower bleed rates

Question 6

What did the AF-PCI trials determine for treatment options regarding antithrombotics?

Answer 6

Low Bleed Risk: consider therapy with warfarin and DAPT

Moderate-High Bleed Risk: Stroke Risk > CV thrombotic risk ⇒ apixaban 5 mg BID + clopidogrel, rivaroxaban 15 mg QD + clopidogrel, dabigatran 150 mg BID + clopidogrel

Question 7

What are patient factors that increase risk of ischemic coronary events?

Answer 7

eGFR <60, prior ACS, prior stent thrombosis, DM, current smoker, clinical presentation was ACS

Question 8

What are angiographic fx that increase risk of ischemic coronary events?

Answer 8

stents deployed, 3 lesions tx, and/or 3 vessels tx, total stent >60 mm, bifurcation lesion stented, left main or proximal LAD stenting, chronic total occlusion intervention, atherectomy performed, bioabsorbable scaffold