Atrial fibrillation medical therapy in patients presenting with ACS and/or PCI or valve intervention
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Atrial fibrillation medical therapy in patients presenting with ACS and/or PCI or valve intervention On the Web | |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Overview
2014 Management of Antithrombotic Therapy in AF Patients Presenting with ACS and/or Undergoing PCI or Valve Interventions: A Joint Consensus Document (DO NOT EDIT)[1]
General
| Class I |
| "1. In AF patients, stroke risk must be assessed using the CHA2-DS2-VASc score, and bleeding risk assessed using the HAS-BLED score. Risk stratification is a dynamic process, and must be performed at regular intervals (i.e. on a yearly basis). (Level of Evidence: C)" |
| "2. Where adjusted dose VKA is used, good quality anticoagulation control is recommended, with a TTR >70%. (Level of Evidence: A)" |
| Class III |
| "1. Novel P2Y12 receptor inhibitors (prasugrel and ticagrelor) should not be part of a triple therapy regimen in patients with AF. (Level of Evidence: C)" |
| Class IIa |
| "1. When VKA is given in combination with clopidogrel and/or low-dose aspirin, the dose intensity of VKA should be carefully regulated, with a target INR range of 2.0–2.5. (Level of Evidence: Grade C)" |
| "2. In a patient with AF and stable vascular disease (arbitrarily defined as being free from any acute ischaemic event or repeat revascularization for >1 year) the patient should be managed with OAC alone (i.e. whether NOAC or a VKA). (Level of Evidence: Grade B)" |
| "3. Radial access should be considered as the default for coronary angiography/intervention to minimize the risk of access related bleeding depending on operator expertise and preference. (Level of Evidence: Grade C)" |
| Class IIb |
| "1. Where aNOACis used in combination with clopidogrel and/or low-dose aspirin, the lower tested dose for stroke prevention in AF (that is, dabigatran 110 mg b.i.d., rivaroxaban 15 mg o.d. or apixaban 2.5 mg b.i.d.) may be considered (Prescribing information for edoxaban awaited.). (Level of Evidence: Grade C)" |
| "2. Newgeneration DES may be preferred over BMS in patients at low risk of bleeding (i.e. HAS-BLED 0–2). (Level of Evidence: Grade C)" |
Stable CAD
| Class I |
| "1. Long-term antithrombotic therapy with OAC (i.e. whether NOAC or a VKA) (beyond 12 months) is recommended in all patients. (Level of Evidence: B)" |
| Class IIa |
| "1. In patients with stable CAD and AF undergoing PCI at lowbleeding risk (HAS-BLED 0–2), triple therapy (OAC, aspirin 75–100 mg daily, clopidogrel 75 mg daily) should be given for a minimum of 4 weeks (and no longer than 6 months) after PCI following which dual therapy with OAC (i.e. whether NOAC or a VKA) and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day) should be continued for up to 12 months. (Level of Evidence: Grade C)" |
| "2. In selected patients with a CHA2DS2-VASc score= 1 (by virtue of their vascular disease only) at low-bleeding risk (HAS-BLED 0–2), dual antiplatelet therapy consisting of aspirin 75–100 mg and clopidogrel 75 mg/day; or dual therapy consisting of OAC (i.e. whether NOAC or a VKA) and clopidogrel 75 mg/day should be considered. (Level of Evidence: Grade C)" |
| "3. In patients with stable CAD and AF undergoing PCI at highbleeding risk (HAS-BLED .3), triple therapy (OAC, aspirin 75–100 mg daily, clopidogrel 75 mg daily) or dual therapy consisting of OAC (i.e. whether NOAC or a VKA) and clopidogrel 75 mg/day should be given for 4 weeks after PCI following which dual therapy with OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day) should be continued for up to 12 months. (Level of Evidence: Grade C)" |
| "4. Gastric protection with PPIs should be considered in patients with OAC plus antiplatelet therapy. (Level of Evidence: Grade C)" |
| "5. WhereOACpatients are at moderate-to-high risk of thromboembolism (i.e. CHA2DS2-VASc ≥2), an uninterrupted anticoagulation strategy with no additional heparin boluses during PCI is the preferred strategy and radial access used as the first choice during therapeutic anticoagulation with a VKA (INR 2–3). This strategy might reduce periprocedural bleeding and thromboembolic events. (Level of Evidence: Grade C)" |
| Class IIb |
| "1. Dual therapy of OAC (i.e. whether NOAC or a VKA) and clopidogrel 75 mg/day may be considered as an alternative to initial triple therapy in selected patients with CHA2DS2- VASc score ≥2. (Level of Evidence: Grade C)" |
| "2. In selected patients with a CHA2DS2-VASc score ¼ 1 at high-bleeding risk (HAS-BLED .3), dual antiplatelet therapy consisting of aspirin 75–100 mg and clopidogrel 75 mg/day; or dual therapy consisting of OAC (i.e. whether NOACor aVKA) and clopidogrel 75 mg/daymay be considered for 12 months. (Level of Evidence: Grade C)" |
| "3. CombinationOACplus single antiplatelet therapy [preferably clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day)] may be considered in only very selected cases, e.g. stenting of the left main, proximal left anterior descending, proximal bifurcation, recurrent MIs, etc.. (Level of Evidence: Grade C)" |
| "4. Where NOAC patients are at moderate-to-high risk of thromboembolism (i.e. CHA2DS2-VASc ≥2), cessation of the drug for 48 h and parenteral anticoagulation as per standard practice during PCI may be prudent in a non-emergency situation. (Level of Evidence: Grade C)" |
| "5. When the procedures require interruption of OAC for longer than 48 h in high-risk patients (i.e. TAVI or other non-PCI procedures at high-bleeding risk), enoxaparin may be administered subcutaneously, although the efficacy of this strategy is uncertain. Pharmacodynamic data suggest that enoxaparin might be a better option than UFH, because of the more predictable and stable level of anticoagulation. Such ‘bridging’ therapies may actually be associated with an excess bleeding risk, possibly due to dual modes of anticoagulation in the
overlap periods.WhenNOACs are used, timing of any bridging therapy should be tailored on the basis of renal function and the pharmacokinetics of the specific NOAC. (Level of Evidence: Grade C)" |
NSTE-ACS Including Unstable Angina and NSTEMI
Primary PCI
Application to General Anticoagulated Patients Who May or May Not Have AF
References
- ↑ Task Force Members. Lip GY, Windecker S, Huber K, Kirchhof P, Marin F; et al. (2014). "Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS)". Eur Heart J. doi:10.1093/eurheartj/ehu298. PMID 25154388.