II. Management: Guidelines

  1. Aspirin or Clopidogrel
    1. Initial Transient Ischemic Attack (TIA)
    2. Initial Ischemic Cerebrovascular Accident (CVA)
    3. Chronic stable Angina
    4. Peripheral Arterial Disease
  2. Aspirin 81 mg and Clopidogrel 75 mg
    1. ST segment elevation Acute Coronary Syndrome
    2. Recurrent Acute Coronary Syndrome
    3. Post-coronary stenting (with Clopidogrel duration based on type of stent)
  3. Aspirin and Extended release Dipyridamole
    1. Recurrent Transient Ischemic Attack (TIA)
    2. Recurrent Ischemic Cerebrovascular Accident (CVA)
  4. Aspirin, Clopidogrel and Warfarin
    1. Triple antithrombotic therapy may at times be indicated
      1. Baseline Atrial Fibrillation or Mechanical Heart Valve with recent coronary stent placement
    2. Avoid triple antithrombotic therapy if at all possible (high bleeding risk)
      1. Serious bleeding in 2% within the first month and 12% in the first year
      2. In some cases Direct Oral Anticoagulants (DOACs) are used in place of Warfarin
      3. In stable heart disease, triple therapy for 3 months after bare stent and 6 months after DES
        1. Then Anticoagulant and Clopidogrel for up to 12 months total
      4. (2017) Presc Lett 24(4): 22
    3. Often Aspirin may be discontinued while on Clopidogrel, Warfarin
      1. Aspirin may then be restarted when Clopidogrel is discontinued
      2. Dewilde (2013) Lancet 381(9872): 1107-15 [PubMed]

III. Protocol: Durations of post-stenting dual Antiplatelet Therapy (e.g. Aspirin 81 AND Clopidogrel)

  1. Duration: 1 month of dual Antiplatelet Therapy (DAPT)
    1. Bare metal stent
  2. Duration: 3 months of dual Antiplatelet Therapy (DAPT)
    1. Gastrointestinal Bleeding event AND stable Ischemic Heart Disease after Drug-eluting Stent
  3. Duration: 6 months of dual Antiplatelet Therapy (DAPT)
    1. Standard duration of DAPT for stable Ischemic Heart Disease after Drug-eluting Stent (as of 2016)
  4. Duration: 12 months of dual Antiplatelet Therapy (DAPT)
    1. Acute Coronary Syndrome event (regardless of stenting)
  5. Duration: 18 months of dual Antiplatelet Therapy (DAPT)
    1. DAPT Score (Dual-Antiplatelet Therapy Decision Rule) of 2 or greater
  6. References
    1. Levine (2016) J Am Coll Cardiol +PMID:27036918 [PubMed]
    2. Yeh (2016) JAMA 315(16):1735-9 [PubMed]

IV. Protocol: Post-Myocardial Infarction

  1. Aspirin 162 mg orally daily indefinately
  2. Clopidogrel (Plavix) added to Aspirin routinely following ST Elevation MI
    1. Dose: 75 mg orally daily (consider initial 300 mg loading dose if age <75 years old)
    2. Duration following ST Elevation MI (typically 12 months)
      1. See Clopidogrel
      2. Continue for at least 14 days and consider one year of therapy in all post-STEMI cases
    3. Stenting-related durations
      1. Bare metal stents require minimum of 1 month of Clopidogrel
      2. Drug-eluting Stents require minimum of >6-12 months (depending on stent-type)
        1. See Angioplasty
  3. References
    1. Antman (2008) Circulation 117(2): 296-329 [PubMed]

V. Precautions: Perioperative Stent Implications

  1. See Angioplasty
  2. Balloon Angioplasty
    1. Time since surgery <14 days: Delay non-urgent or elective surgery
    2. Time since surgery >14 days: Proceed to surgery with Aspirin
  3. Bare-Metal Stent
    1. Time since surgery <30-45 days: Delay non-urgent or elective surgery
    2. Time since surgery >45-90 days: Proceed to surgery with Aspirin
  4. Drug-eluting Stent
    1. Time since surgery <365 days: Delay non-urgent or elective surgery
    2. Time since surgery >365 days: Proceed to surgery with Aspirin
  5. Minimum dual antiplatelet time for stents
    1. Dual Antiplatelet Therapy should be continued for one year with all drug eluting stents
      1. Deviation from the one year minimum is for serious extenuating circumstances
      2. All deviations from the one year minimum should be discussed with cardiology
    2. Balloon Angioplasty: >2 weeks
    3. Bare metal stents: >1 month
    4. Sirolimus (Rapamune) eluting stents: >3 months
    5. All other Drug-eluting Stents: >6-12 months

VI. Management: Gastrointestinal prophylaxis

  1. Proton Pump Inhibitors are often used for peptic ulcer prevention while on combined anti-platelet agents
    1. Ranitidine has been used more commonly for GI prophylaxis due to potential Cytochrome P450 2C19 drug interaction with Proton Pump Inhibitors
  2. Cytochrome P450 2C19 drug interaction with Proton Pump Inhibitors has potential to predispose to more post-stenting events
    1. Cogent study (see Bhatt below) left open that this interaction may be important
    2. Studies have not observed an increase in number of cardiovascular events
      1. Ho (2009) JAMA 301: 937-44 [PubMed]
      2. Bhatt (2010) N Engl J Med 363:1909-17 [PubMed]

VII. Protocol: Perioperative Plavix

  1. Precautions
    1. See perioperative stenting implications above
    2. Mortality doubles in Acute Coronary Syndrome patients in first 90 days after stopping Plavix
      1. Consider tapering off by taking every other day for 2-3 weeks
      2. Conitinue Aspirin 162 after stopping Plavix
      3. Ho (2008) JAMA 299(5):532-9 [PubMed]
  2. Timing of stopping Plavix (if no contraindications)
    1. Stop 7 days before surgery (delay surgery if too soon after cardiovascular event)

VIII. Protocol: Perioperative Aspirin

  1. Precautions
    1. Aspirin used for secondary prevention
      1. Stopping Aspirin before surgery resulted in a 3 fold increased risk of cardiovascular events
    2. Aspirin used after coronary stenting
      1. Stopping Aspirin before surgery resulted in a 90 fold increasd risk of cardiovascular events
  2. Protocol
    1. Consult with surgeon regarding whether Aspirin may be continued
    2. Low dose Aspirin can be continued in the perioperative period for most surgeries
      1. Avoid Aspirin prior to intracranial surgery
      2. Avoid Aspirin prior to Prostatectomy
    3. Surgical bleeding risk increases with Aspirin by 20%
      1. However, no increase in severe bleeding for most surgeries (except intracranial surgery or Prostatectomy)
  3. References
    1. Eberli (2010) J Urol 183(6): 2128-36 [PubMed]
    2. Burger (2005) J Intern Med 257(5): 399-414 [PubMed]
    3. Biondi-Zoccai (2006) Eur Heart J 27(22): 2667-74 [PubMed]

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Ontology: Antiplatelet therapy (C1096021)

Concepts Therapeutic or Preventive Procedure (T061)
Italian Terapia antipiastrinica
Japanese 抗血小板療法, コウケッショウバンリョウホウ
Czech Antiagregační léčba
English antiplatelet therapy, Antiplatelet therapy
Hungarian Thrombocyta-gátló kezelés
Portuguese Tratamento anti-plaquetas
Spanish Tratamiento antiplaquetario
Dutch antibloedplaatjestherapie
French Traitement antiplaquettaire
German Therapie mit Thrombozytenaggregationshemmer