ANTIPLATELET GUIDELINES Flashcards
High Risk of Thrombotic Events
Prior MI or trop positive ACS
DM on oral meds or insulin
CKD (CrCl < 60)
Previous stent thrombosis
Current smoker
> /3 stents
Long lesion > 60 mm total stent
Complex lesion (bifurcation with 2 stents, chronic occlusion)
Lt main or proximal LAD
Multivessel PCI
Risk Factors for Bleeding
OAC + DAPT
> 75
Frailty
Hgb < 110
CRF (CrCl < 40)
BW < 60 kg
Hospitalization for bleed < 1 yr
Previous stroke / ICB
Regular need for NSAID or Prednisone
Duration of DAPT in Patients with ACS (STEMI or NSTEMI) who Undergo PCI
DAPT for 1 year
Preferred DAPT in Patients with ACS (STEMI or NSTEMI) who Undergo PCI
ASA 81 mg once daily +Ticagrelor 90 mg BID or Prasugrel 10 mg once daily
preferred over Clopidogrel 75 mg once daily
What do you reassess at 1 year in Patients with ACS (STEMI or NSTEMI) who Undergo PCI on DAPT
At 1 year, determine bleeding risk
Recommendations at 1 year for patients with ACS (STEMI or NSTEMI) who Undergo PCI on DAPT with low bleeding risk
Continue DAPT for up to 3 years
ASA 81 mg once daily +Ticagrelor 60 mg BID or
Clopidogrel 75 mg once daily2
Recommendations at 1 year for patients with ACS (STEMI or NSTEMI) who Undergo PCI on DAPT with high bleeding risk
SAPT
ASA 81 mg once daily or
Clopidogrel 75 mg once daily
Duration of DAPT in Patients who Undergo Elective PCI Not at high risk of bleeding
DAPT for 6 months
ASA + clopidogrel
Duration of DAPT in Patients who Undergo Elective PCI at high risk of bleeding
DAPT for 1 month if BMS,
or 3 months if DES
THEN
SAPT
ASA 81 mg daily or
Clopidogrel 75 mg daily
Duration of DAPT in Patients who Undergo Elective PCI with High-risk clinical or angiographic features for thrombotic cardiovascular events,
and not at high risk of bleeding
Extend DAPT up to 3 years
ASA 81 mg daily + Clopidogrel 75 mg daily
Interrupting DAPT for Non-Cardiac Surgery: BMS
recommend delaying surgery for at least 1 month after PC
Continue ASA perioperatively
withhold clopidogrel and ticagrelor for 5-7 days pre-operatively
withold prasugrel for 7-10 days pre-operatively
Interrupting DAPT for Non-Cardiac Surgery: DES
recommend delaying surgery
for at least 3 months after PCI
Continue ASA perioperatively
withhold clopidogrel and ticagrelor for 5-7 days pre-operatively
withold prasugrel for 7-10 days pre-operatively
When to restart DAPT in PCI after non cardiac surgery
restart maintenance dose after surgery, as soon as it is deemed safe by the surgeon
Management of DAPT for Elective or Semi-urgent CABG Surgery after ACS (minimum vs. ideal)
continuation of ASA
minimum interruption of ticagrelor and clopidogrel for 48-72 hours before CABG ideal interruption period of 5 days before elective CABG
minimum interruption of prasugrel for 5 days before CABG and recommend an ideal interruption period of 7 days before elective CABG
Switching from clopidogrel to ticagrelor
Loading dose: 180 mg
Maintenance dose: 90 mg twice daily
Timing: regardless of the timing of the last clopidogrel dose
Switching from clopidogrel to prasugrel
Loading dose: 60 mg
Maintenance dose: 10 mg daily
Timing: regardless of the timing of the last clopidogrel dose
Switching from prasugrel to ticagrelor
Loading dose: None
Maintenance dose: 90 mg twice daily
Timing: At next scheduled dose
Switching from ticagrelor to prasugrel
Loading dose: 60 mg
Maintenance dose: 10 mg daily
Timing: At next scheduled ticagrelor dose
Switching from ticagrelor to clopidogrel
Loading dose: Optional loading 300-600 mg *
Maintenance dose: 75 mg daily
Timing: At next scheduled ticagrelor dose†
Switching from prasurgel to clopidogrel
Loading dose: None
Maintenance dose: 75 mg daily
Timing: At next scheduled dose
Patients with AF without High-Risk Features who Undergo Elective PCI: Age < 65 and CHADS2 = 0
ASA + Clopidogrel
Duration: at least 1 month for BMS and at
least 3 months for DES (and up to 12 months)
Patients with AF without High-Risk Features who Undergo Elective PCI: Age ≥ 65 or CHADS2 ≥ 1
OAC2 + Clopidogrel
Duration: at least 1 month for BMS and at
least 3 months for DES (and up to 12 months)
Patients with AF who Undergo PCI for ACS or High-Risk Elective PCI: Age < 65 and CHADS2 = 0
ASA + P2Y12 inhibitor2
(ticagrelor, prasugrel preferred
over clopidogrel for ACS)
Duration after PCI: Up to 12 months
Patients with AF who Undergo PCI for ACS or High-Risk Elective PCI: Age ≥ 65 or CHADS2 ≥ 1
Reduced OAC3 + ASA + clopidogrel
ASA: stop 1 day post PCI or any time up to 6 months4
Followed by: clopidogrel + OAC
Duration after PCI: Up to 12 months
Patients with Venous Thromboembolism OR established left ventricular thrombus Undergoing PCI for an ACS or non-ACS indication
initial regimen of ASA 81 mg daily plus clopidogrel 75 mg daily plus either parenteral OR oral anticoagulation (in accordance with
DVT/PE recommendations).
ASA may be discontinued as early as the day following PCI or it can be continued up to 6 months of treatment, depending on the risk of recurrent ischemic events versus major bleeding.
Following ASA discontinuation, we suggest that OAC plus clopidogrel
75 mg daily be continued for up to 12 months after the initial PCI
In patients undergoing PCI for an ACS indication who are high-risk of developing LV thrombus
DAPT with ASA 81 mg daily plus either ticagrelor 90 mg twice daily or prasugrel 10 mg once daily
for up to 1 year
In patients with a mechanical valve replacement who undergo PCI for an ACS or non-ACS indication:
ASA 81 mg daily plus clopidogrel 75 mg daily plus a vitamin
K antagonist (VKA) (triple therapy).
ASA may be discontinued as early as the day after PCI or it can be continued up to 6 months of treatment,
In patients with a surgical bioprosthetic valve replacement (implanted < 6 months) who undergo PCI for an ACS or non-ACS indication:
DAPT with ASA 81 mg daily and clopidogrel
75 mg daily for at least 6 months (and up to 12 months)
In patients with a transcatheter aortic valve replacement (TAVR) (implanted < 6 months) who undergo PCI for an ACS or non-ACS indication:
DAPT with ASA 81 mg daily and
clopidogrel 75 mg daily for 3-6 months
