Coronary heart disease secondary prevention antiplatelet agents/anticoagulants

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Antiplatelet Agents and Anticoagulants

2011 AHA/ACCF Guidelines for Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease (DO NOT EDIT) [1]

Antiplatelet agents and Anticoagulants (DO NOT EDIT) [1]

Class I

"1. Aspirin 75–162 mg daily is recommended in all patients with coronary artery disease unless contraindicated. [2][3][4][5] (Level A)

  • Clopidogrel 75 mg daily is recommended as an alternative for patients who are intolerant of or allergic to aspirin. [6] (Level B)"

"2. A P2Y12 receptor antagonist in combination with aspirin is indicated in patients after ACS or PCI with stent placement. [7][8][9] (Level A)

  • For patients receiving a bare-metal stent or drug-eluting stent during PCI for ACS, clopidogrel 75 mg daily, prasugrel 10 mg daily, or ticagrelor 90 mg twice daily should be given for at least 12 months. [8][10][11][12] (Level A)"

"3. For patients undergoing coronary artery bypass grafting, aspirin should be started within 6 hours after surgery to reduce saphenous vein graft closure. Dosing regimens ranging from 100 to 325 mg daily for 1 year appear to be efficacious. (Level A)"

"4. In patients with extracranial carotid or vertebral atherosclerosis who have had ischemic stroke or TIA, treatment with aspirin alone (75–325 mg daily), clopidogrel alone (75 mg daily), or the combination of aspirin plus extended-release dipyridamole (25 mg and 200 mg twice daily, respectively) should be started and continued. (Level B)"

"5. For patients with symptomatic atherosclerotic peripheral artery disease of the lower extremity, antiplatelet therapy with aspirin (75–325 mg daily) or clopidogrel (75 mg daily) should be started and continued. (Level A)"

"6. Antiplatelet therapy is recommended in preference to anticoagulant therapy with warfarin or other vitamin K antagonists to treat patients with atherosclerosis. (Level A)

  • If there is a compelling indication for anticoagulant therapy, such as atrial fibrillation, prosthetic heart valve, left ventricular thrombus, or concomitant venous thromboembolic disease, warfarin should be administered in addition to the low-dose aspirin (75–81 mg daily). (Level A)
  • For patients requiring warfarin, therapy should be administered to achieve the recommended INR for the specific condition. (Level B)
  • Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of bleeding and should be monitored closely. (Level A)"
Class IIa

"1. If the risk of morbidity from bleeding outweighs the anticipated benefit afforded by thienopyridine therapy after stent implantation, earlier discontinuation (eg, <12 months) is reasonable. (Level C) (Note: the risk for serious cardiovascular events because of early discontinuation of thienopyridines is greater for patients with drug-eluting stents than those with bare-metal stents.)"

"2. After PCI, it is reasonable to use 81 mg of aspirin per day in preference to higher maintenance doses. (Level B)"

"3. For patients undergoing coronary artery bypass grafting, clopidogrel (75 mg daily) is a reasonable alternative in patients who are intolerant of or allergic to aspirin. (Level C)"

Class IIb

"1. The benefits of aspirin in patients with asymptomatic peripheral artery disease of the lower extremities are not well established. (Level B)"

"2. Combination therapy with both aspirin 75 to 162 mg daily and clopidogrel 75 mg daily may be considered in patients with stable coronary artery disease. (Level B"

Sources

  • 2011 AHA/ACCF Guidelines for Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Aterosclerotic Vascular Disease (DO NOT EDIT) [1]

References

  1. ↑ 1.0 1.1 1.2 Smith SC, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA; et al. (2011). "AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation". Circulation. 124 (22): 2458–73. doi:10.1161/CIR.0b013e318235eb4d. PMID 22052934.
  2. ↑ Gibbons RJ, Abrams J, Chatterjee K; et al. (2003). "ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina)". Circulation. 107 (1): 149–58. PMID 12515758. Unknown parameter |month= ignored (help)
  3. ↑ Vandvik PO, Lincoff AM, Gore JM; et al. (2012). "Primary and secondary prevention of cardiovascular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e637S–68S. doi:10.1378/chest.11-2306. PMID 22315274. Unknown parameter |month= ignored (help)
  4. ↑ Baigent C, Blackwell L, Collins R; et al. (2009). "Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials". Lancet. 373 (9678): 1849–60. doi:10.1016/S0140-6736(09)60503-1. PMC 2715005. PMID 19482214. Unknown parameter |month= ignored (help)
  5. ↑ "Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients". BMJ. 324 (7329): 71–86. 2002. PMC 64503. PMID 11786451. Unknown parameter |month= ignored (help)
  6. ↑ "A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee". Lancet. 348 (9038): 1329–39. 1996. PMID 8918275. Unknown parameter |month= ignored (help)
  7. ↑ Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK (2001). "Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation". N. Engl. J. Med. 345 (7): 494–502. doi:10.1056/NEJMoa010746. PMID 11519503. Unknown parameter |month= ignored (help)
  8. ↑ 8.0 8.1 Mehta SR, Yusuf S, Peters RJ; et al. (2001). "Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study". Lancet. 358 (9281): 527–33. PMID 11520521. Unknown parameter |month= ignored (help)
  9. ↑ Steinhubl SR, Berger PB, Mann JT; et al. (2002). "Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial". JAMA. 288 (19): 2411–20. PMID 12435254. Unknown parameter |month= ignored (help)
  10. ↑ Montalescot G, Wiviott SD, Braunwald E; et al. (2009). "Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial". Lancet. 373 (9665): 723–31. doi:10.1016/S0140-6736(09)60441-4. PMID 19249633. Unknown parameter |month= ignored (help)
  11. ↑ Wiviott SD, Braunwald E, McCabe CH; et al. (2007). "Prasugrel versus clopidogrel in patients with acute coronary syndromes". N. Engl. J. Med. 357 (20): 2001–15. doi:10.1056/NEJMoa0706482. PMID 17982182. Unknown parameter |month= ignored (help)
  12. ↑ Wallentin L, Becker RC, Budaj A; et al. (2009). "Ticagrelor versus clopidogrel in patients with acute coronary syndromes". N. Engl. J. Med. 361 (11): 1045–57. doi:10.1056/NEJMoa0904327. PMID 19717846. Unknown parameter |month= ignored (help)


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