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

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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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