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Antiplatelet and Anticoagulation Therapy-What You Need to Know PowerPoint Presentation

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Description : Check out this medical presentation on Atrial Fibrillation, which is titled "Antiplatelet and Anticoagulation Therapy – What You Need to Know", to know about the current practice guidelines for the management of antiplatelet therapy in CAD patients, the selection of different antiplatelet medications, the optimal duration of Dual Antiplatelet therapy, and know the options of anticoagulation in atrial fibrillation.

Tags : Atrial Fibrillation, Antiplatelet, Anticoagulation Therapy, CAD patients, antiplatelet medications

Published on : Jun 02, 2021 | Views : 2044 | Downloads : 5

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Slide 1-

Sumith Aleti, MD, MPH, FACC OHHI Cardiology Group Antiplatelet and Anticoagulation Therapy – What You Need to Know
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Objectives Utilize current practice guidelines for the management of antiplatelet therapy in CAD patients. Discuss the selection of different antiplatelet medications Determine optimal duration of Dual Antiplatelet therapy Assess CV risk vs bleeding risk Recognize options of of anticoagulation in atrial fibrillation
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ANTIPLATELETS
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Collagen Thrombin TXA2 ADP ADP=Adenosine diphosphate, COX=Cyclooxygenase, TXA2=Thromboxane A2 Clopidogrel bisulfate TXA2 Phosphodiesterase ADP Activation COX Ticlopidine hydrochloride Aspirin Gp 2b/3a Inhibitors Dipyridamole Cilostasol Source: Schafer AI. Antiplatelet Therapy. Am J Med 1996;101:199–209 Prasugrel hydrochloride Antiplatelet Therapy: Targets Ticagrelor
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Aspirin for Primary Prevention Aspirin reduces the risk of myocardial Infarction among men (Physician’s Health Study (PHS) Aspirin does not reduce cardiovascular events among women (Women’s Health Study) Aspirin decreases risk of ischemic stroke in woman but not in men. Aspirin does not reduce the risk of adverse CV events in diabetics (POPADAD study and Japanese PAD study) Aspirin reduces the risk of MI and vascular events at the expense of bleeding (ATT collaboration)
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Aspirin (81 mg daily or 100 mg every other day) in at risk women >65 years of age Aspirin in at risk women <65 years of age for ischemic stroke prevention Aspirin in optimal risk women <65 years of age Aspirin Recommendations Primary Prevention Source: Mosca L et al. Circulation 2007;115:1481-1501
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Aspirin (75-162 mg daily) in [men]* at intermediate risk (10-year risk of CHD >10%) For diabetics only for (10-year risk >10%) and for men >50 years of age or women >60 years of age who have at least one additional major risk factor Low-dose aspirin (75-162 mg/day) may be considered for those with DM at intermediate CVD risk (younger patients with >1 risk factors* or older patients with no risk factors*, or patients with a 10-year risk of 5-10%.‡ Aspirin Recommendations (Continued) Primary Prevention CHD=Coronary heart disease *Specific guideline recommendations for men do not exist, but these guidelines are based on previous general (not gender specific) primary prevention guidelines Source: Pearson TA et al. Circulation 2002;106:388-391 Includes those with family history of premature CVD, hypertension, smoking, dyslipidemia, or albuminuria
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Source: Antithrombotic Trialists’ Collaboration. BMJ 2002;324:71–86 Category % Odds Reduction Acute MI Acute CVA Prior MI Prior CVA/TIA Other high risk CVD (e.g. unstable angina, heart failure) PAD (e.g. intermittent claudication) High risk of embolism (e.g. Afib) Other (e.g. DM) All trials 1.0 0.5 0.0 1.5 2.0 Control better Antiplatelet better Effect of antiplatelet treatment* on vascular events** *Aspirin was the predominant antiplatelet agent studied **Include MI, stroke, or death Aspirin Evidence: Secondary Prevention Aspirin reduces the risk of adverse cardiovascular events
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CLOPIDOGREL
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Clopidogrel: Secondary Prevention Clopidogrel provides slightly greater risk reduction than aspirin DAP therapy produces greater benefit when used for 1 year in NSTE-ACS patients DAP therapy produces greater benefit when used for 1 year in post PCI patients. DAP therapy produces greater benefit in medically managed STEMI patients Routine use of DAP for high risk patients showed no benefit over aspirin alone.
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PRASUGREL
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Source: Wiviott SD et al. NEJM 2007;357:2001-2015 Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel (TRITON-TIMI 38) 0 5 9 60 90 180 270 360 450 HR 0.81, P=0.0004 Prasugrel Clopidogrel HR 0.80 P=.001 HR 0.77 P=.001 Days CV death, MI, or stroke % 12.1 9.9 Bleeding Events C (%) P (%) P-value TIMI major 1.8 2.4 .03 Life threatening 0.9 1.4 .01 Nonfatal 0.9 1.1 .23 Fatal 0.1 0.4 .002 ICH 0.3 0.3 .74 13,608 patients with high-risk ACS scheduled for PCI randomized to clopidogrel (300 mg LD and 75 mg MD) or prasugrel (60 mg LD and 10 mg MD) for a median of 12 months 7 11 ACS=Acute coronary syndrome, ICH=Intracranial hemorrhage, LD=Loading dose, MD=Maintenance dose Prasugrel Evidence: Secondary Prevention 0 30 Prasugrel reduces ischemic events with a higher rate of bleeding
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Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY-ACS) Prasugrel Evidence: Secondary Prevention HR=0.91, P=0.21 CV Death, Nonfatal MI, and Nonfatal Stroke (%) 0 10 20 Time (Days) 0 360 720 16.0% 13.9% Clopidogrel Prasugrel Source: Roe, MT et al. NEJM 2012;367:1297-1309 CV=Cardiovascular, MI=Myocardial infarction, NSTE-ACS=Non-ST-segment elevation acute coronary syndrome 7243 patients with a medically managed NSTE-ACS randomized to prasugrel (10 mg) or clopidogrel for up to 30 months Prasugrel does not provide benefit in medically managed NSTE-ACS
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Prasugrel: Summary *In pts with no prior stroke or TIA. 1. Amsterdam EA, et al. Circulation. 2014;130:2354-2394.
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TICAGRELOR
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Platelet Inhibition and Patient Outcomes (PLATO) Study 18,624 patients with a moderate to high risk ACS randomized to clopidogrel (300-600 mg LD and 75 mg MD) or ticagrelor (180 mg LD and 90 mg twice daily MD) for 12 months Source: Wallentin L et al. NEJM 2009;361:1045-1057 Ticagrelor reduces ischemic events with no higher rate of bleeding overall Days after randomization ACS=Acute coronary syndrome, CV=Cardiovascular, LD=Loading dose, MD=Maintenance dose *No statistically significant differences were observed in bleeding rates overall Ticagrelor Evidence: Secondary Prevention
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Invasive (coronary angiography followed by revascularization) PLATO: CV Death, MI, or Stroke in ACS Pts With or Without Invasive Strategy 20 16 12 8 4 0 360 300 240 180 120 60 0 Noninvasive HR: 0.85 (95% CI: 0.73-1.0) Invasive HR: 0.84 (95% CI: 0.75-0.94) 12.0% 14.3% 9.0% 10.7% Days After Randomization CV Death, MI, or Stroke (%) Ticagrelor +ASA (n = 6732) Clopidogrel + ASA (n = 6676) Noninvasive Ticagrelor + ASA (n = 2601) Clopidogrel + ASA (n = 2615) James SK, et al. BMJ. 2011;342:d3527
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PEGASUS–TIMI 54: CV Death, MI, or Stroke in Pts With Prior MI and ≥ 1 Risk Factor* Bonaca MP, et al. N Engl J Med. 2015;372:1791-1800. *65 yrs of age or older, diabetes, second prior MI, multivessel CAD, or chronic non-end stage renal dysfunction. 10 8 6 4 2 0 0 36 6 12 18 24 30 Mos From Randomization CV Death, MI, or Stroke (%) N = 21,162 Median follow-up: 33 mos 9.0% 7.8% 7.8% Placebo Ticagrelor 90 mg Ticagrelor 60 mg Ticagrelor 90 mg HR: 0.85 (95% CI 0.75-0.96; P = .008) Ticagrelor 60 mg HR: 0.84 (95% CI 0.74-0.95; P = .004)
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0.85 (0.75-0.96) 0.84 (0.74-0.95) 0.84 (0.76-0.94) 0.87 (0.71-1.06) 0.83 (0.68-1.01) 0.85 (0.71-1.00) 0.81 (0.69-0.95) 0.84 (0.72-0.98) 0.83 (0.72-0.95) 0.82 (0.63-1.07) 0.75 (0.57-0.98) 0.78 (0.62-0.98) .008 .004 .001 .15 .07 .06 .01 .03 .005 .14 .03 .03 CV Death, MI, or Stroke (1558 events) CV Death (566 events) MI (898 events) Stroke (313 events) Endpoint HR (95% CI) P Value 0.4 0.6 0.8 1 1.25 1.67 Ticagrelor Better Placebo Better Ticagrelor 90 mg Ticagrelor 60 mg Pooled Bonaca MP, et al. N Engl J Med. 2015;372:1791-1800. PEGASUS–TIMI 54: Components of Primary Endpoint
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DAPT After Stent Implantation
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Bleeding vs Ischemic risk Ferreiro et al Thromb Haemost 2010; 103: 1128–1135
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Lets simplify Aspirin dose in PCI patients – 81 is enough Regardless of stent type ideal duration is 1 year DAPT in PCI for Stable ischemic heart disease DAPT in PCI for ACS patients Bleed risk – (previous bleed on DAPT, on oral anticoagulation, has coagulopathy etc)
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Stable Ischemic Heart disease DAPT consists of ASA + Clopidogrel Bare metal – 1 month minimum Current DES stents – 6 months minimum If no bleed risk continue longer in both groups. May be reasonable to stop P2Y12inh after 3 months if patient developed significant overt bleeding, or at risk for severe bleeding complication (e.g. major intracranial surgery)
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ACS patients At least 12 months for both BMS and DES patients. Reasonable to prefer Ticagrelor over Clopidogrel Reasonable to prefer Prasugrel over Clopidogrel if patient not at high bleeding risk and do not have CVA If no bleeding complication or bleed risk low, may continue longer than 12 months. DES patients may discontinue P2Y12 after 6 months if high bleed risk.
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Anticoagulation in Atrial fibrillation
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ACC/AHA Guidelines 2014 Antithrombotic therapy is recommended for all patients with atrial fibrillation except those with low risk (grade IA) Use CHA2DS2-VASC score to calculate CVA risk in nonvalvular afib (grade IA) Assessment of bleeding risk should be done when prescribing oral anticoagulation therapy (grade IA) Where oral anticoagulation indicated, a DOAC should be used instead of warfarin (grade IIA)
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CHA2DS2VASC & Risk Stratification *AHA/ACC 2014 atrial fibrillation guidelines 27
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When to Anticoagulate *AHA/ACC 2014 atrial fibrillation guidelines 28 Using the CHA2DS2VASC score: Score of 0 = no anticoagulation Score of 1 = none (if point awarded for gender only), or aspirin, or oral anticoagulation Score of >2 = oral anticoagulation
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Direct Oral Anticoagulation (DOAC) Examples Direct thrombin inhibitor Dabigatran (Pradaxa) Direct factor Xa inhibitor Rivaroxaban (Xarelto) Apixaban (Eliquis) Edoxaban (Savaysa) Betrixaban (Bevyxxa) 29
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Warfarin Preferred for patients with: Mechanical heart valves Valvular afib: mitral stenosis or mitral valve replacement Breastfeeding End stage renal disease 30
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Conclusions DAPT is indicated at least for one year after ACS Duration of antiplatelet therapy is based on ischemic vs bleed risk Newer generation stents, DAPT duration shorter in special situations In patients with prior MI, benefit with extending DAPT beyond one year Calculate bleeding risk for ischemic risk in assessing duration