Combining Antiplatelets and Anticoagulants Flashcards
WOEST
RCT of 573 AF patients undergoing PCI Bleed rates compared over 1 year Warfarin and clopidogrel alone lower than Warfarin, clopidogrel and ASA Not powered for outcome of death, MI, stroke, TVR and stent thrombosis but ‘appeared’ lower in the warfarin and clopidogrel alone group
DOAC AF-PCI Trials - Commonalities
Typical patient – white male in his 70s with NVAF and CHADS2
-VASC of 4 and HASBLED of 3 who underwent PCI for ACS or stable angina
DOAC regimens with SAPT or DAPT
Note dosing of DOAC differs from stroke indication in some cases
Only AUGUSTUS compared regimens with and without ASA
Length of therapy determined by PCI indication and investigator
Primary outcome of major bleeding (+/-CRNM) versus a warfarin regimen
Not powered for efficacy outcomes
Bleeding Definitions
Major bleeds
Clinically relevant non-major bleeding (CRNMB)
Major bleeds can be catastrophic resulting in mortality, intensive
care admissions or extended hospital stays. All trials included these
bleeding events.
Clinically relevant non-major bleeding (CRNMB) impact the quality
of life for our patients, and consists of emergency room treatment, physician intervention to stop bleeding, or temporary or permanent
discontinuation of antithrombotic therapy. Relative to major
bleeding, CRNMB occurs more frequently. Importantly, not all trials
measured this type of bleeding.
AF-PCI Trials
3 trials
comparator was warfarin
RE -DUAL • Dabigatran 110mg BID plus clopidogrel • Dabigatran 150mg BID plus clopidogrel • Triple therapy
PIONEER AF PCI • Rivaroxaban 15mg daily plus clopidogrel • Rivaroxaban 2.5mg BID plus DAPT • Triple therapy
AUGUSTUS • Apixaban 5mg BID plus clopidogrel • Warfarin plus clopidogrel • Comparison of regimens with and without ASA
Dual Pathway or Dual Therapy is not same as
Dual Antiplatelet Therapy (DAPT)
dual pathway/tx is anticoagulant + antiplatelet
AF PCI Trials – Options
Low bleed risk
Consider standard therapy with warfarin and DAPT
Moderate to high bleed risk possibilities
Stroke risk > CV thrombotic risk
Apixaban 5mg BID plus clopidogrel
Rivaroxaban 15mg daily plus clopidogrel
Dabigatran 150mg BID plus clopidogrel
CV thrombotic risk > stroke risk
Rivaroxaban 2.5mg BID plus DAPT
decide if stroke risk or thrombotic risk is higher
higher stroke risk -> full dose rivar, dabi full dose, slightly lower than full dose of apix
higher thrombotic risk
rivr (wont see used much)
Case A
70 year old white male with atrial fibrillation
CHADS-VASC score of 3 (no previous stroke)
HASBLED of 5
Elective PCI with DES – no high risk features
Normal renal function, no diabetes
Assessment
bleed risk
stroke risk
cardiac thrombotic risk
how would you rank his risks with
respect to treatment choices?
Bleed risk > stroke risk > thrombotic risk
HASBLED is 9% for major bleed
Elective PCI with DES -> not due to ACS, risk is highest right after
which of the following regimens
would you suggest? for case A
Warfarin plus clopidogrel for 3 months
Rivaroxaban 2.5mg BID plus DAPT for 3 months
Rivaroxaban 15mg daily plus clopidogrel for 3 months
Apixaban 5mg BID plus clopidogrel for 3 months
Rivaroxaban 15mg daily plus clopidogrel for 3 months
shorten duration, not 6 monts
Poll – Patient was started on rivaroxaban
15mg daily plus clopidogrel. What should
happen after 3 months?
Continue rivaroxaban 15mg daily and discontinue clopidogrel
Change rivaroxaban to 20mg daily and discontinue clopidogrel
Change rivaroxaban to 2.5mg BID and discontinue clopidogrel
Continue rivaroxaban 15mg daily and change clopidogrel to ASA
Change rivaroxaban to 20mg daily and discontinue clopidogrel
need to go back to full dose of AF tx!
case b 70 year old white male with atrial fibrillation CHADS-VASC score of 5 (previous stroke) HASBLED of 4 PCI for ACS Normal renal function
Assessment
bleed risk
stroke risk
cardiac thrombotic risk
Stroke risk > thrombotic risk > bleed risk
5.8% major bleed
stroke 6.7%
case b – which of the following regimens
would you suggest?
Warfarin, clopidogrel and ASA for 12 months
Rivaroxaban 2.5mg BID plus DAPT for 12 months
Rivaroxaban 15mg daily plus ASA and clopidogrel with ASA stopped one
month post PCI. Then rivaroxaban 15mg daily plus clopidogrel for 11
months
Apixaban 5mg BID plus ASA and clopidogrel with ASA stopped day 1 post
PCI. Then apixaban 5mg BID plus clopidogrel for 12 months
Rivaroxaban 15mg daily plus ASA and clopidogrel with ASA stopped one
month post PCI. Then rivaroxaban 15mg daily plus clopidogrel for 11
months
Apixaban 5mg BID plus ASA and clopidogrel with ASA stopped day 1 post
PCI. Then apixaban 5mg BID plus clopidogrel for 12 months
more than 1 right answer
maybe PPI for bleed isk
case b
Patient received apixaban 5mg BID
plus clopidogrel for 12 months. Now what?
Continue apixaban 5mg BID alone
Continue apixaban 5mg BID plus clopidogrel
Continue apixaban 5mg BID and change clopidogrel to ASA
Change apixaban to 2.5mg BID, continue clopidogrel and add ASA
Continue apixaban 5mg BID alone
high bleed risk, another anticoag increase bleed risk and dont want him on antiplatelet
Beyond AF and PCI?
dose for vte not same as AF
Other indications for anticoagulation
Need for warfarin (i.e. mechanical valves)
Alternate dosing regimens for DOACs (i.e. VTE treatment)
Key Patient Counselling Elements
Indication / benefit of EACH component of therapy
Duration of EACH component of therapy and timing of reassessment
Start date and stop date for each agent
Plan after completion of course of therapy for each agents
Other agents continue at same dose OR
Other agents continue at different dose OR
A different agent is resumed or added
Need for reassessment of therapy by a healthcare professional
Risk / benefit of therapy should be reassessed with
Occurrence of thrombotic events
Occurrence of bleeding – major bleeds, CRNMB and nuisance bleeding
Changes in other medical conditions
Changes in drug therapy for other medical conditions
Peri-procedural regimens
