Atrial fibrillation medical therapy in patients presenting with ACS and/or PCI or valve intervention

Resident Survival Guide

Atrial Fibrillation Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Atrial Fibrillation from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Special Groups Postoperative AF Acute Myocardial Infarction Wolff-Parkinson-White Preexcitation Syndrome Hypertrophic Cardiomyopathy Hyperthyroidism Pulmonary Diseases Pregnancy ACS and/or PCI or valve intervention Heart failure
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram EKG Examples A-Fib with LBBB
Chest X Ray
Echocardiography
Holter Monitoring and Exercise Stress Testing
Cardiac MRI
Treatment
Rate and Rhythm Control
Cardioversion Overview Electrical Cardioversion Pharmacological Cardioversion
Anticoagulation Overview Warfarin Converting from or to Warfarin Converting from or to Parenteral Anticoagulants Dabigatran
Maintenance of Sinus Rhythm
Surgery Catheter Ablation AV Nodal Ablation Surgical Ablation Cardiac Surgery
Specific Patient Groups
Primary Prevention
Secondary Prevention
Supportive Trial Data
Cost-Effectiveness of Therapy
Case Studies
Case #1
Atrial fibrillation medical therapy in patients presenting with ACS and/or PCI or valve intervention On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Atrial fibrillation medical therapy in patients presenting with ACS and/or PCI or valve intervention
CDC on Atrial fibrillation medical therapy in patients presenting with ACS and/or PCI or valve intervention
Atrial fibrillation medical therapy in patients presenting with ACS and/or PCI or valve intervention in the news
Blogs on Atrial fibrillation medical therapy in patients presenting with ACS and/or PCI or valve intervention
Directions to Hospitals Treating Atrial fibrillation medical therapy in patients presenting with ACS and/or PCI or valve intervention
Risk calculators and risk factors for Atrial fibrillation medical therapy in patients presenting with ACS and/or PCI or valve intervention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

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)

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= 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. Combination OAC plus 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

Class I

"1. Long-term antithrombotic therapy (beyond 12 months) is recommended with OAC whether with VKA or a NOAC in all patients. (Level of Evidence: B)"

Class IIa

"1. Patients with moderate-to-high-risk NSTE-ACS and AF at low risk of bleeding (HAS-BLED 0–2) should receive dual antiplatelet therapy with aspirin plus clopidogrel andOAC (i.e. whether NOAC or a VKA) should also be given/continued. (Level of Evidence: Grade C)"

"2. An early invasive strategy (within 24 h) should be preferred among patients with moderate-to-high-risk NSTE-ACS in order to expedite treatment allocation (medical vs. PCI vs. CABG) and to determine the optimal antithrombotic regimen. (a) Pre-treatment with glycoprotein (GP) IIb/IIIa inhibitors should be avoided in such patients. (b) Pre-treatment with P2Y12 receptor antagonists may be withheld until the time of coronary angiography in case of an early invasive strategy within 24 h. (Level of Evidence: Grade C)"

"3. When a parenteral anticoagulant is needed to support PCI in a patient at high risk of bleeding, bivalirudin should be considered as an alternative to unfractionated heparin. (Level of Evidence: Grade A)"

"4. When a parenteral anticoagulant is needed to support PCI in a patient at lowrisk of bleeding, bivalirudin should be considered as alternative to unfractionated heparin. (Level of Evidence: Grade B)"

"5. In patients with ACS and AF at lowrisk of bleeding (HAS-BLED 0–2), the initial use of triple therapy (OAC, aspirin, and clopidogrel) should be considered for 6 months following PCI irrespective of stent type; this should be followed by long-term therapy (up to 12 months) with OAC and clopidogrel 75 mg/ day (or alternatively, aspirin 75–100 mg/day). (Level of Evidence: Grade C)"

"6. In patients withACS and AF at high risk of bleeding (HAS-BLED ≥3), the initial use of triple therapy (OAC, aspirin, and clopidogrel) should be considered for 4weeks following PCI irrespective of stent type; this should be followed by long-term therapy (up to 12 months) with OAC and a single antiplatelet drug (preferably clopidogrel 75 mg/day, or as an alternative, aspirin 75–100 mg/day). (Level of Evidence: Grade C)"

Class IIb

"1. In the ACS setting, patients are often given aspirin, clopidogrel, heparin (whether UFH or enoxaparin) or bivalirudin and/or a GP IIb/IIIa inhibitors. Given the risk of ischaemia and bleeding it may be prudent to stop OAC (i.e. whether NOAC or a VKA) therapy, and where a VKA or NOAC is used, administer UFH or bivalirudin only as bailout (but avoiding GP IIb/IIa inhibitors) or if INR ≤2 in a patient on VKA, balancing the acute need for additional antithrombotic therapy with the excess bleeding risk and the ‘thrombus burden’. (Level of Evidence: Grade C)"

"2. In low-risk ACS patients with delayed transfer for an invasive strategy at .24 h of admission, it may be prudent to stop OAC therapy and bridge the patient with unfractionated heparin or enoxaparin. (Level of Evidence: Grade C)"

"3. For a NOAC, cessation of the drug for 36–48 h (based on the biological half-life of the respective agents and the actual kidney function) may be prudent. (Level of Evidence: Grade B)"

"4. In selected patients with aCHA2DS2-VASc score ≥2 at low risk of bleeding (HAS-BLED 0–2), continuation of triple therapy or dual antiplatelet therapy consisting of OAC (i.e. whether NOAC or a VKA) and clopidogrel 75 mg/day may be considered between 6 and 12 months. (Level of Evidence: Grade C)"

"5. As an alternative to initial triple therapy in selected patients at high risk of bleeding (e.g. HAS-BLED ≥3) and low risk of stent thrombosis/recurrent ischaemic events, dual therapy consisting of OAC and clopidogrel 75 mg/day may be considered. (Level of Evidence: Grade C)"

"6. Combination OAC plus single antiplatelet therapy (preferably clopidogrel 75 mg/day, or as an alternative, aspirin 75–100 mg/day) may be considered in very selected cases, e.g. stenting of the left main, proximal left anterior descending, proximal bifurcation, recurrent MIs, etc. (Level of Evidence: Grade B)"

"7. The use of ticagrelor or prasugrel in combination with OAC may only be considered under certain circumstances (e.g. definite stent thrombosis while on clopidogrel, aspirin, and OAC). (Level of Evidence: Grade C)"

References

Template:WikiDoc Sources