Anticoagulation? Antiplatelet? What’s the Score?
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Dear Gurus:
I need your help.
My patient Mr. J is 78 years old and has chronic atrial fibrillation and hypertension. He
receives warfarin to decrease the thromboembolic risk related to the atrial fibrillation.
Two weeks ago he presented with unstable angina. There was no evidence of MI. He
underwent coronary angiography and was found to have a 95% stenosis of the
proximal LAD and no other coronary artery disease. PTCA was performed and a bare
metal stent implanted. He was discharged taking warfarin + aspirin + clopidogrel.
I saw him today and he is doing well.
The question I have for you relates to his anticoagulant – antithrombotic therapy. I
know that he requires the warfarin to decrease the risk of stroke related to atrial
fibrillation and requires the dual antiplatelet therapy to decrease the risk of stent
thrombosis. The triple anticoagulant – antiplatelet therapy though puts him at risk of
bleeding.
How would you sages handle this one?JoeCorncob Hospital
Dear Gurus:
I need your help.
My patient Mr. J is 78 years old and has chronic atrial fibrillation and hypertension. He
receives warfarin to decrease the thromboembolic risk related to the atrial fibrillation.
Two weeks ago he presented with unstable angina. There was no evidence of MI. He
underwent coronary angiography and was found to have a 95% stenosis of the
proximal LAD and no other coronary artery disease. PTCA was performed and a bare
metal stent implanted. He was discharged taking warfarin + aspirin + clopidogrel.
I saw him today and he is doing well.
The question I have for you relates to his anticoagulant – antithrombotic therapy. I
know that he requires the warfarin to decrease the risk of stroke related to atrial
fibrillation and requires the dual antiplatelet therapy to decrease the risk of stent
thrombosis. The triple anticoagulant – antiplatelet therapy though puts him at risk of
bleeding.
How would you sages handle this one?JoeCorncob Hospital
Issues for Mr. J
Atrial fibrillation: thromboembolic riskRecent stent: stent thrombosis riskTriple oral anticoagulant therapy: bleeding risk
Copyright © 2015
How do we determine stroke risk?
CHADS2 Congestive heart failure - 1pt Hypertension - 1pt Age > 75 - 1 pt Diabetes - 1pt Stroke or TIA - 2 pts
0 points – low risk (1.2-3.0 strokes per 100 patient years) 1-2 points – moderate risk (2.8-4.0 strokes per 100 patient years) > 3 points – high risk (5.9-18.2 strokes per 100 patient years)
*Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of Clinical Classification Schemes for Predicting Stroke: Results From the National Registry of Atrial Fibrillation. JAMA. 2001;285(22):2864-2870.
You JJ, Singer DE, Howard PA, et al. Antithrombotic therapy for atrial fibrillation. Chest. 2012;141(2_suppl):e531S-e575S.
Lip G, et al. Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based Approach: The Euro Heart Survey on
Atrial Fibrillation. Chest. 2010;137(2):263-272.
CHA2DS2- VASc score = 4
Lip Y, et al. Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based
Approach.Chest. 2010, 137(2):263.
CHADS2 vs. CHA2DS2VASc
CHADS2 score 0: 1.4% events
CHA2DS2-VASc 0: 0 events
CHA2DS2-VASc score 1: 0.6% events
CHA2DS2-VASc score 2: 1.6% events
CHA2DS2VASc score > 2= high risk
Copyright © 2015
*Lip G, et al. Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based Approach: The Euro Heart Survey on Atrial Fibrillation. Chest. 2010;137(2):263-272.
Dual Antiplatelet Guideline
Copyright © 2015
Bare metal stent 4-6 weeks, then ASA long term
Drug eluting stent 12 months, then ASA long term
NSTEMI 12 months
STEMI 12 months
Our Approach to Chronic Atrial Fibrillation & Stenting
Low stroke risk (CHADS2 0-1) + stent Dual antiplatelet therapy
Moderate-high risk (CHADS2 >2) + stent Bare metal stent
Warfarin + one month of dual antiplatelet therapy then: Warfarin + aspirin (low dose)
Drug eluting stent Warfarin + 12 months dual antiplatelet therapy then Warfarin + aspirin (low dose)
Novel oral anticoagulants not studied in this setting
Copyright © 2015
Mr. J
Copyright © 2015
High risk embolic phenomena Continue warfarin
BMS two weeks ago Continue aspirin long term Continue clopidogrel for another 2 weeks
and then discontinue (total duration dual antiplatelet therapy 4 weeks)
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