CV Update – Guidelines & DebatesCV Update – Guidelines & DebatesRoyal Pharmaceutical Society, Great Britain Royal Pharmaceutical Society, Great Britain

Barnet – 27/01/09Barnet – 27/01/09

Dr Ameet Bakhai, FRCP

– Cardiologist, Clinical Trials, Health Economics

Barnet & Chase Farm NHS Trust

Royal Free NHS Trust, University of Hertfordshire

Bushey Spire

Conflict of Interest: Consultant to companies, Research Grants

Work with NICE, AMORE Health, Health Smart UK

Atherothrombosis Significantly Shortens

Life Expectancy (Prognosis) at 60

Framingham Heart StudyPeeters et al. Eur Heart J 2002; 23: 458–466

Healthy History of Angina

History of MI

History of CVA

02

46

8

10

12

14

16

1820

Yea

rs

9.27.4 12

www.nclcn.org.uk

Oral Anti-Platelet Therapy Maintenance for Cardiovascular Risk / Disease v2.0 DraftProduced by NCL CVD Prevention Task Group primary author Dr Ameet Bakhai- Review Date Jan 2010.

NCL Cardiac and Stroke Network

Ischaemic Stroke/TIA (no AF)Dipyridamole SR 200mg bd 2 years plus Aspirin 75mgs daily

OrAspirin 75mg daily (for patients

intolerant to dipyridamole)Or

Clopidogrel 75mgs daily for aspirin allergic patients

Recurrent Strokes / TIAs (no AF)(whilst on aspirin and dipyridimole)

No evidence base to provide guidance on changing to different anti-platelet agent

ST elevation MI without stentAspirin 75mg daily

Clopidogrel 75mg daily 12 months*

ST elevation MI with stentAspirin 75mg daily

Clopidogrel 75mg daily for 12 months*

Non-ST elevation MI / Unstable angina with / without stent

Aspirin 75mg dailyClopidogrel 75mg daily for 12 months*

Chronic Stable Angina without recent event (>12 months) / Peripheral Arterial Disease

Aspirin 75mg daily

Drug Eluting Stent with / without MIAspirin 75mg daily

Clopidogrel 75mg daily for 12 months*

Bare Metal Stent with / without MI / UAAspirin 75mg daily

Clopidogrel 75mg daily for 4 weeks*

Patient on Aspirin with GI symptoms or previous ulcer with either age ≥ 60 or also using another anti-platelet / warfarin / corticosteroids/ NSAIDs / SSRIs should have PPI cover.^

Ensure medication is taken with food. Eradicate H Pylori as needed. Add Lansoprazole 30mg / Omeprazole 20mg daily (check outcome).

Patient with a new gastro-intestinal bleed

Discontinue aspirin and clopidogrel. Liaise with cardiologist

and gastroenterologist urgently

Aspirin Allergy

(bronchospasm or angio-oedema) or rash, associated with administration of aspirin

Clopidogrel 75mg

Asymptomatic, Age≥50,

10 year CVD risk ≥20%

Aspirin 75 mg daily after Baseline BP≤150 / 90

Asymptomatic with Diabetes Mellitus (I or II) with any of:Age≥40 / metabolic syndrome /≥10 year DM / HbA1c≥9% / Tchol ≥

6mmol/l / on drugs for BP / organ damage / family history of premature coronary disease (M≤55, F≤65)

Aspirin 75 mg daily after Baseline BP≤150 / 90

* In certain situations cardiologist may specify

shorter or longer clopidogrel duration

Primary Secondary

When anti-platelet therapy is initiated in secondary care a clear written indication, which includes duration, should be recorded and communicated to primary care. Where a duration is NOT specified it is assumed the drug is to be continued long term. For complex patients not covered by these simplified guidelines - please contact the supervising consultant or Dr A Bakhai to assist. Ensure duration of therapy is flagged on GP’s clinical notes if NOT for long term. Recommend for clopidogrel – patients issued a clopidogrel patient card. For aspirin - enteric aspirin does not appear to confer advantage #..

References: NICE – Vascular Disease guidance TA090NICE – NSTE -ACS guidance TA080NICE – Post MI guidance (Mar 07)Joint British Society Guidance 2 (2005). Clopidogrel 12 mths – local consensus. ^Circulation 28.10.08 #National Prescribing Centre MeReC Bulletin 2005;15

Atrial fibrillation pts for antithrombotic but not for anticoagulants: warfarin

Aspirin 75 mg daily after Baseline BP≤150 / 90

United Kingdom Clinical Pharmacy Association (cardiac group) Clopidogrel Patient Cardhttp://www.ukcpa.org/?pid=0&lsid=3593&edname=22554.htm&ped=22554