They are currently used by millions of Americans to prevent thrombotic complications in a wide variety of cardiovascular conditions.1  When combined, these medications increase the risk of significant bleeding complications. Double antiplatelet therapy (DAT) with Clopidogrel plus Aspirin for TIA and minor ischemic stroke has been widely supported by several clinical trials, allowing its indication in clinical practice guidelines. For patients whose recurrent risk for VTE is low, discontinuing anticoagulant therapy may be reasonable if a strong indication for antiplatelet therapy exists. A P2Y12 inhibitor-based monotherapy after a short period of dual antiplatelet therapy is emerging as a plausible strategy to decrease bleeding.. Choosing the optimal antithrombotic regimen can be a challenge. 2020 Feb 26;15:1-3. doi: 10.15420/ecr.2019.09. Applying the findings from these trials will help individual patients and their health care providers balance potential benefits and risks when selecting appropriate antithrombotic regimens. Efficacy and safety of dual antiplatelet therapy and risk stratification tools 3.1 DAPT for the prevention of stent thrombosis 3.2 DAPT for the prevention of spontaneous myocardial infarction 3.3 DAPT and … Results: From 265 manuscripts reviewed, four trials involving 7,953 patients were selected. Live. He is overweight but not obese (90 kg, body mass index of 27.0). Dual antiplatelet therapy (DAPT) increases the risk of surgical bleeding complications. Recent studies have compared different combinations of antiplatelet and anticoagulant medications for a variety of cardiovascular conditions. Third, patients who need combined use of anticoagulants and antiplatelet medications are at increased risk for upper gastrointestinal (GI) bleeding. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines … Others may have concomitant VTE. Dual Antiplatelet Therapy in Coronary Artery Disease: Comparison Between ACC/AHA 2016 and ESC 2017 Guidelines Eur Cardiol . All studies were open-label. Copyright ©2020 by American Society of Hematology, What Hematologists Need to Know About Giving and Stopping Aspirin, Combined anticoagulant–antiplatelet use by patients with multiple indications, Combined anticoagulant–antiplatelet use by patients with atherosclerotic disease, https://doi.org/10.1182/hematology.2020000151, Prior intracranial bleed, cardiogenic shock, recent peptic ulcer or major bleeding, or thrombocytopenia, Prior stroke, recent GI bleeding event, CrCl <30 mL/min, or anemia (Hg <10 g/dL), Cardiac valve replacement (mechanical or bioprosthetic) or CrCl <30 mL/min, Anticoagulant use for indications other than AF, severe renal insufficiency, prior intracranial bleed, recent or planned coronary artery bypass graft surgery, or ongoing bleeding, Mechanical heart valve, moderate to severe mitral stenosis, and end-stage renal disease, Patients with recent ACS and additional risk factors for recurrent ischemic events, Patients with PAD undergoing revascularization, Severe hypertension, CrCl < 20 mL/min, active bleeding, recent ischemic stroke, NYHA class IV heart failure, prior intracranial bleeding, anemia (Hg <9 g/dL), thrombocytopenia, ongoing use of anticoagulation or aspirin >325 mg daily, Thrombocytopenia, anemia (Hg <10 g/dL), CrCl <30 mL/min, High risk of bleeding, recent stroke, severe heart failure, estimated glomerular filtration rate <15 mL/min, use of dual antiplatelet therapy, or anticoagulation use, Unstable clinical condition, high risk for bleeding, or long-term use of clopidogrel (beyond 6 mo). The ACC has released a new Expert Consensus Decision Pathway providing guidance and recommendations on optimal antithrombotic therapy … This recommendation is also supported by a class IIa recommendation from the 2019 American Heart Association/American College of Cardiology guideline on AF management and the 2018 European Consensus guidelines.17,31, Second, use of a DOAC is preferred to warfarin when combined with either single antiplatelet or DAPT therapy. However, for patients with acute VTE in the first 1 to 3 weeks of therapy, caution is advised if DAPT is combined with higher daily doses of either apixaban or rivaroxaban. ... Where possible, avoid the use of dual antiplatelet therapy (DAPT) and/or a combination of antiplatelet therapy … Many patients have comorbid conditions that each have indications for different antithrombotic medications. Combined use of anticoagulant and antiplatelet medications is common for patients with comorbid cardiovascular conditions, including CAD, AF, and VTE. While triple therapy … First, bleeding is a significant concern when anticoagulants are combined with DAPT, as has been shown in the AF plus CAD studies outlined earlier. In fact, most patients in the randomized trials detailed earlier used clopidogrel rather than prasugrel or ticagrelor. In the subsequent COMPASS trial, patients with stable CAD or peripheral artery disease (PAD; including carotid artery disease) were randomly assigned to receive rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily, rivaroxaban 5 mg twice daily without aspirin, or aspirin 100 mg daily.29  The composite primary outcome of cardiovascular death, stroke, or MI occurred less often among patients randomly assigned to rivaroxaban 2.5 mg twice daily plus aspirin than among patients taking aspirin alone. For patients taking DOAC medications who require PCI, most DOACs can be held for no more than 36-48 hours prior to the procedure. • A 10- to 21-day course of dual antiplatelet therapy reduces stroke recurrence and improves quality of life after mild stroke or high-risk TIA. A similar study, APPRAISE-2, randomly assigned patients with ACS to receive apixaban 5 mg twice a day or placebo in addition to DAPT.28  This study was stopped prematurely because of an excess of major bleeding events among patients taking apixaban plus DAPT (2.4 vs 0.9 per 100 patient-years, HR 2.59; 95% CI, 1.50-4.46). Although evidence in favor of this recommendation is less robust than evidence for therapy in the first 6 to 12 months after PCI, 2 recent trials demonstrated relative safety with regard to both bleeding outcomes and thromboembolic events (eg, MI, death).21,22  Some degree of caution is advised because 1 study was terminated prematurely for failure to enroll,22  and the other was conducted in a purely Japanese population.21  Nevertheless, concurrent use of oral anticoagulation with aspirin for patients with AF and stable CAD remains common and will probably require further efforts to promote deprescribing, including rigorous evaluation of these deprescribing efforts.23, Although the data on anticoagulation alone versus anticoagulation plus single antiplatelet therapy are limited for patients with stable CAD, there is more robust evidence that aspirin may have net clinical harm for primary prevention of atherosclerotic disease.2  This is particularly true for patients taking chronic anticoagulant therapy but without a clear indication for concurrent antiplatelet treatment.24  Efforts to reduce aspirin use in this population may lead to reductions in medication-related adverse events, including hospitalizations.25, Although data have rapidly emerged on the risks and benefits of double versus triple antithrombotic therapy for patients taking oral anticoagulants for stroke prevention in AF, much less data is available for patients with VTE who need PCI. The minimal duration of dual antiplatelet therapy (DAPT) has evolved with the evolution of drug eluting stent (DES) technology. Pulmonary Hypertension and Venous Thromboembolism. The patient is a 65-year-old man who presented to the hospital with new chest discomfort at rest. Adult … For people undergoing dental surgery antiplatelet therapy … If triple therapy is needed, a short duration (e.g., no more than 30 days) is recommended. For patients on antiplatelet therapy who develop a new VTE event, use of anticoagulation plus single antiplatelet medication is generally recommended. In the study of Borghol et al, more of 20% of strokes had NIHSS score ≥5. Patients using antiplatelet therapy for primary cardiovascular disease prevention or >12 months from the most recent PCI or acute coronary syndrome can be treated with anticoagulation monotherapy. Therefore, concurrent indications for multiple antithrombotic agents is a common clinical scenario. Citation: 2020 ACC Expert Consensus Decision Pathway for Anticoagulant and Antiplatelet Therapy in Patients With Atrial … Conflict-of-interest disclosure: G.D.B. Geoffrey D. Barnes, Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, 2800 Plymouth Rd B14 G214, Ann Arbor, Michigan 48109-2800; email: gbarnes@umich.edu. Antithrombotic agents, consisting of antiplatelet and anticoagulant medications, are some of the most commonly prescribed medications. Combined use of very low-dose rivaroxaban plus aspirin has also demonstrated benefit in atherosclerotic diseases, including coronary and peripheral artery disease. Background While dual antiplatelet therapy (dAPT) is standard of care following carotid artery stenting (CAS), the optimal dAPT regimen and duration has not been established. For patients with AF on anticoagulation who need a PCI, use of a direct oral anticoagulant (DOAC) is preferred over a vitamin K antagonist (VKA) when appropriate. discloses grant funding from the National Heart, Lung, and Blood Institute (K01HL135392), Agency for Healthcare Quality and Innovation (R18HS026874 and R21HS026322), and Blue Cross Blue Shield of Michigan. This usage is based, in part, on a series of studies published before 2005 demonstrating reductions in MI risk.2  Daily aspirin therapy was widely recommended in both clinical guidelines and the lay media, leading to broad application both with and without health care provider involvement. If aspirin is being used, it should be limited to <100 mg daily dosing. Clinical pathways are suggested for four potential clinical situations: (1) prior AF on anticoagulation and the need for PCI; (2) new-onset AF requiring anticoagulation in a patient already on antiplatelet therapy for coronary artery disease (CAD); (3) prior VTE on anticoagulation and the need for PCI; and (4) new or recurrent VTE requiring anticoagulation in a patient already on antiplatelet therapy for CAD. Strategies to reduce bleeding risk for patients with AF and CAD. Aspirin therapy has been used for decades to prevent and treat cardiovascular disease, including myocardial infarction (MI) and ischemic stroke. Aspirin is often combined with a P2Y12 receptor antagonist (clopidogrel, prasugrel, or ticagrelor) for dual antiplatelet therapy (DAPT) after PCI or ACS.3,4  Aspirin monotherapy or DAPT may also be used to prevent major adverse cardiovascular events for patients with peripheral artery disease.5  Oral anticoagulants, including warfarin and the direct oral anticoagulants (DOACs), are used for a wide range of thrombotic disorders, most commonly to prevent stroke and systemic embolism associated with AF and to prevent or treat venous thromboembolism (VTE). The most recent American College of Cardiology/American Heart Association guidelines on duration of dual‐antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug‐eluting … Timeline of antithrombotic therapy in atrial fibrillation and coronary artery disease. For PCI for stable angina, a shorter course of clopidogrel and ASA (≤7 days) may be more appropriate (indicated by dark shaded arrows). Guidelines Issued on Antithrombotic Therapy in Certain Patients with AF or VTE. © 2020 by The American Society of Hematology. [2020] Also see the NICE technology appraisal guidance on ticagrelor for the … However, concerns remain regarding long-term PPI use and risk of cardiovascular disease, renal insufficiency, Clostridium difficile infection, and fracture risk.38  Guidelines from both North America and Europe recommend PPI use for patients taking combined anticoagulant–anticoagulant therapy given that the reduction in elevated GI bleeding risk probably outweighs any potential drug-related adverse event risk.17,39  It is also important to address PPI deprescribing once the bleeding risk has been mitigated (eg, transition to anticoagulation monotherapy). For patients taking ≥2 antithrombotic agents, starting or continuing a proton pump inhibitor and avoiding other anti-inflammatory medications should be employed to reduce gastrointestinal bleeding risk. Although major bleeding was higher in the rivaroxaban–aspirin combination group, there was no increased in intracranial or fatal bleeding as compared with aspirin monotherapy, a key distinction from the ATLAS ACS 2-TIMI 51 study results.27  Most recently, the VOYAGER study randomly assigned patients with PAD who had undergone revascularization to receive rivaroxaban 2.5 mg twice daily or placebo in addition to aspirin.30  Patients receiving both rivaroxaban and aspirin experienced fewer thrombotic events (composite of acute limb ischemia, major amputation for vascular causes, MI, ischemic stroke, or cardiovascular death) than patients receiving aspirin monotherapy. The point estimate favoured dual antiplatelet therapy, and that's a group of CKD patients where we see greater absolute risk reductions in PEGASUS. The patient’s hospitalist and interventional cardiologist discuss the risks and benefits of various combinations of antithrombotic agents. [2020] 4 Moreover, the average duration of antiplatelet therapy was 313.7 days in the mono antiplatelet therapy group and 239 days in the dual antiplatelet therapy … In fact, recent guidelines and expert consensus documents recommend shorter courses of triple therapy for most of these patients.16-18  This recommendation is supported by 2 recent meta-analyses showing lower rates of bleeding when dual therapy (an anticoagulant plus P2Y12 inhibitor) rather than triple therapy is used.19,20  This is particularly true for the combination of a DOAC plus P2Y12 inhibitor and is similar in both stable CAD and ACS. When combined with an anticoagulant, clopidogrel is the recommended antiplatelet agent for most patients. CrCl, creatinine clearance; Hg, hemoglobin; ISTH, International Society on Thrombosis and Haemostasis; PAD, peripheral artery disease; TIMI, Thrombolysis in Myocardial Infarction; TT, triple therapy. For PCI with stable ischemic heart disease or acute coronary syndrome, use of oral anticoagulant plus a P2Y, Management of patients with prior VTE depends on the clinical situation during which the VTE event occurred. However, rivaroxaban may be administered at 15 mg daily (reduce to 10 mg daily for creatinine clearance <50 ml/min) when combined with P2Y. Longer courses of clopidogrel use may be appropriate for patients with high ischemic risk or who experience an ACS. Anticoagulation Management and Atrial Fibrillation. In 2016, the ACC/AHA released updated guidelines on duration of dual antiplatelet therapy (DAPT) in patients with coronary artery disease. The hospitalists recommended use of a PPI to help minimize bleeding risk while the patient was taking multiple antithrombotic medications. Oral anticoagulation plus P2Y, For patients on antiplatelet therapy who develop new AF, management depends on the indication for antiplatelet therapy. Up to 10% of the >3 million Americans with atrial fibrillation will experience an acute coronary syndrome or undergo percutaneous coronary intervention. Although reducing the total number of antithrombotic medications is highly effective at reducing bleeding risk, this is not always feasible and does not completely eliminate bleeding risk for patients. However, patients in the double therapy group also had fewer thrombotic events or deaths (11.1% vs 17.6%; HR 0.60; 95% CI, 0.38-0.94), including fewer MI, stroke, and stent thrombosis events. In the past 5 years, a number of randomized clinical trials have explored different combinations of anticoagulation plus antiplatelet agents aimed at minimizing bleeding risk while preserving low thrombotic event rates. Guidelines recommend 3 to 6 months of dual antiplatelet therapy after transcatheter aortic valve replacement (TAVR) (NEJM JW Cardiol Apr 24 2017), but this approach is based on expert … This duration is selected because the patient experienced an ACS event. Independent of the need for ongoing anticoagulant therapy, recent studies have suggested that shorter courses of DAPT (sometimes ≤3 months) may be appropriate for many patients undergoing PCI.14,15  Therefore, many cardiovascular specialists, including interventional cardiologists, are recommending shorter courses of DAPT for patients after PCI or an ACS if they are taking concurrent anticoagulant medications (Figure 1). In this focused update, the term and acronym … Collectively, when the warfarin–clopidogrel–aspirin triple therapy combination was compared with the apixaban–clopidogrel double therapy combination, only 9 patients needed to be treated with the apixaban–clopidogrel regimen to avoid 1 major or clinically relevant nonmajor bleeding event. He has a history of atrial fibrillation (AF), for which he takes warfarin to prevent stroke, but no prior history of atherosclerotic cardiovascular disease or bleeding events. If long-term/indefinite anticoagulation is required, then use of standard treatment doses of anticoagulation plus P2Y. In addition, related studies have shown that dual antiplatelet therapy has a higher bleeding risk than single antiplatelet therapy (Diener et al., 2004; Bhatt et al., 2006). Second, although major bleeding often increases with combined anticoagulant–antiplatelet combinations, fatal and intracranial hemorrhage risk appear to be increased when a third antiplatelet medication (eg, P2Y12 inhibitor) is included. For primary cardiovascular prevention, switch to anticoagulation monotherapy is recommended. Because he experiences an ACS, the interventional cardiologist feels more comfortable continuing aspirin 81 mg daily for 30 days, but then agrees to stop aspirin and continue dual therapy (apixaban and clopidogrel) for the remainder of the 12 months. 2020 ACC Expert Consensus Decision Pathway for Anticoagulant and Antiplatelet Therapy in Patients With Atrial Fibrillation or Venous Thromboembolism Undergoing Percutaneous Coronary Intervention or With Atherosclerotic Cardiovascular Disease: A Report of the American College of Cardiology Solution Set Oversight Committee. Before he is discharged from the hospital, his physician wonders what the safest antithrombotic regimen to balance bleeding and thrombotic risk would be, given his known AF and recent ACS with PCI. The following are key points to remember from the 2020 ACC expert consensus decision pathway for anticoagulant and antiplatelet therapy in patients with atrial fibrillation (AF) or venous thromboembolism (VTE) undergoing percutaneous coronary intervention (PCI) or with atherosclerotic cardiovascular disease: Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, Anticoagulation Management and Venothromboembolism, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine, Chronic Angina, Keywords: Acute Coronary Syndrome, Angina, Stable, Angina, Unstable, Anticoagulants, Aspirin, Arrhythmias, Cardiac, Atherosclerosis, Atrial Fibrillation, Carotid Artery Diseases, Cerebrovascular Disorders, Coronary Artery Disease, Creatinine, Fibrinolytic Agents, Geriatrics, Hemorrhage, Myocardial Ischemia, Percutaneous Coronary Intervention, Peripheral Arterial Disease, Peripheral Vascular Diseases, Platelet Aggregation Inhibitors, Proton Pump Inhibitors, Pulmonary Embolism, Secondary Prevention, ST Elevation Myocardial Infarction, Stents, Therapeutics, Thromboembolism, Thrombosis, Vascular Diseases, Venous Thromboembolism, Venous Thrombosis, Vitamin K. © 2021 American College of Cardiology Foundation. Principal Findings: The primary outcome, cardiac death, nonfatal myocardial infarction, target-vessel revascularization, stroke, or major bleeding at 12 months, occurred in 5.9% of the 1 … INSPIRE Study Investigators (International Collaboration of Aspirin Trials for Recurrent Venous Thromboembolism), Aspirin for the prevention of recurrent venous thromboembolism: the INSPIRE collaboration, Rivaroxaban in patients with a recent acute coronary syndrome, Apixaban with antiplatelet therapy after acute coronary syndrome, Rivaroxaban with or without aspirin in stable cardiovascular disease, Rivaroxaban in peripheral artery disease after revascularization, 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in collaboration with the Society of Thoracic Surgeons, Risk of major bleeding in different indications for new oral anticoagulants: insights from a meta-analysis of approved dosages from 50 randomized trials, Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report [published correction appears in, Association of proton pump inhibitors with reduced risk of warfarin-related serious upper gastrointestinal bleeding, Association of oral anticoagulants and proton pump inhibitor cotherapy with hospitalization for upper gastrointestinal tract bleeding, Pantoprazole to prevent gastroduodenal events in patients receiving rivaroxaban and/or aspirin in a randomized, double-blind, placebo-controlled trial, Missed opportunities to prevent upper GI hemorrhage: the experience of the Michigan Anticoagulation Quality Improvement Initiative, Adverse effects associated with proton pump inhibitors, American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents, ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. 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