Table of contents
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Based on Canadian Cardiology Society (CCS) Guidelines 2012
and AHA NSTE-ACS Guidelines 2004 (2009 update)
Post-ACS Anti-Platelet Therapies
(For PCI, CABG, or Medical Therapy Alone)
NSTEMI/UA
- ASA 81mg daily indefinitely in ALL patients (Strong, High)
PLUS - Ticagrelor 90mg BID x12mo (in patients with moderate-to-high NSTEACS risk)
- If anatomy defined, and PCI is planned: Prasugrel > clopidogrel (Strong, High)
- AVOID Prasugrel in pts with prev. TIA, Stroke, or if not treated with PCI
- AVOID Prasugrel before coronary anatomy is defined
- AVOID Prasugrel in CABG
- 2nd Line: clopidogrel
- Use 150mg daily for first 6 days post-PCI (for ACS) (Strong, Moderate)
- If anatomy defined, and PCI is planned: Prasugrel > clopidogrel (Strong, High)
- Switch patents from clopidogrel to others?
- Only switch if had stent thrombosis (switch to ticagrelor or prasugrel), bleeding, CV event [Strong, Low]
- DAPT beyond 12mo --> only if high risk of thrombosis and low bleeding risk
STEMI
- If Fibrinolytics OR Medically Managed:
- ASA + Clopidogrel 75mg daily for > 1mo [at least]
- Suggest clopidogrel for at least 12mo [conditional, low]
- ASA + Clopidogrel 75mg daily for > 1mo [at least]
- If PCI reperfused:
- ASA + (either Ticagrelor 90mg BID OR Prasugrel 10mg daily x12mo)
- 2nd Line: ASA + Clopidogrel 75mg daily x12mo (if not eligible for prasugrel/ticagrelor) [Strong, Moderate]
- (Clopidogrel 150mg daily x first 6 days post-PCI)
- NOTE: Prasugrel avoid if prev TIA/stroke (higher risk of intracranial bleed), reduce dose to 5mg in pts >75yo or ≤ 60kg
- 2nd Line: ASA + Clopidogrel 75mg daily x12mo (if not eligible for prasugrel/ticagrelor) [Strong, Moderate]
- ASA + (either Ticagrelor 90mg BID OR Prasugrel 10mg daily x12mo)
Non-ACS Stented Patients
- ASA + clopidogrel x1year
- (AT LEAST 1mo of ASA/clopidogrel for Bare-Metal Stents)
- (AT LEAST 3mo of ASA/clopidogrel for Drug-Eluting Stents if cannot manage 1yr)
Anticoagulation
- STEMI
- If thrombolysis or medical management --> Anticoagulate x48hrs (heparin/LMWH/fondaparinux)
- If PCI --> Discuss with interventionalist (probably not), they can start heparin post-Cath based on anatomy
- NSTEMI/UA
- RECOMMENDED in addition to antiplatelet therapy regardless of treatment strategy
- Enoxaparin 1mg/kg SC q12h (once daily if CrCl < 30 mL/min) continue while in hospital or until PCI performed
- Loading dose of 30mg IV can be used in some patients.
- ESSENCE Trial (better than UFH), treated for 48h-8days.
- Bivalirudin 0.10 mg/kg load + 0.25mg/kg/hr (only if early invasive - going for PCI, continue until PCI)
- Fondaparinux: 2.5mg SC daily (continue while in hospital or until PCI performed)
- IF PCI while on fonda --> add Anti-IIa activity (UFH or bivalirudin) due to risk of catheter thrombosis
- UFH IV: Initial load of 60 IU/kg (max 4000 IU) + infuse @ 12 IU/kg/hr (max 1000 iu/hr) adjust to aPPT x48hrs or until PCI performed
CABG
Before Surgery
- Ideally (if pt stable)
- Clopidogrel + Ticagrelor d/c 5d prior to OR
- Prasugrel d/c 7d prior to OR
- If Unstable --> Weigh risks/benefits of bleeding
After Surgery
- If ACS
- DAPT for 12mo for ACS pts post-CABG [Strong, Moderate]
- Prevents early graft occlusion (conflicting data) and CV events (clear data).
- Clopidogrel, Prasugrel, and Ticagrelor demonstrate benefits post-CABG.
- DAPT for 12mo for ACS pts post-CABG [Strong, Moderate]
- If Elective
- Single Anti-platelet (usually ASA) post-CABG
- Start DAPT within 48-72hrs post-OP (or as per CV surgery team)
NOACs for ACS
- Big push b/c platelets + coagulation factors involved in ACS
- Not recommended (despite benefit) [Strong, High]
- Rivaroxaban+Clopidogrel+ASA
- Improves composite (CV death, MI, stroke, total mortality)
- Increased risk of bleeding complications, and high cost
- Practially "triple therapy" OAC + DAPT may be warranted (i.e. ACS + AFib or mechanical valve)
- However, be careful with bleeding risk
- Literature:
- Apixaban + DAPT (ASA + plavix) did not reduce vascular events, but increased major fatal bleeds.
- Dabigatran + DAPT increased risk of bleeding (not powered to assess vascular events)
- Rivaroxaban (very low dose) + DAPT = significant vascular mortality benefit (increased ICH/fatal bleeds)
Other Pearls
PPI + Clopidogrel
- SELETIVE use of PPI in patients with DAPT (only if high GI bleed risk)
- CYP2C19 inhibition reduces effect of clopidogrel
- Do not use routinely in all patients with DAPT, but only in those with high UGI bleed risk.
- Avoid omeprazole and esomeprazole with clopidogrel (inhibit CYP2C19 --> decr. clopidogrel activity)
- Panto is preferred
ASA + NSAIDs
- AVOID
Stents in High-Bleeding patients
-
Low Risk of Bleed High Risk of Bleed VERY HIGH RISK BLEED Bare Metal Stent 3mo of DAPT [Strong, High] 1mo of DAPT [Cond, Low] 2 weeks of DAPT [Cond, Low] Drug Eluting Stent 1yr of DAPT [Strong, High] 3mo of DAPT [Cond, Low]
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