Links To “#400 Antiplatelets, Anticoagulation for Coronary Artery Disease and Afib” From The Curbsiders

Today, I reviewed, excerpt, and link to The Curbsiders‘ [Episode List] #400 Antiplatelets, Anticoagulation for Coronary Artery Disease and Afib, Jun 19, 2023, by Matthew Watto, MD.

All that follows is from the above resource.

Download the Transcript

Master the prescription of antiplatelets and anticoagulation for coronary artery disease and afib (atrial fibrillation). We discuss why, when, and how long to prescribe aspirin, clopidogrel, ticagrelor, prasugrel, and/or anticoagulation for primary, secondary, and “primary and a half” prevention including the definition and discussion of mono, dual, and triple therapy for patients with coronary disease who need anticoagulation for atrial fibrillation. We’re joined by preventive cardiologist, Dr. Donald Lloyd-Jones MD, ScM (@dmljmd from NMCardioVasc)! This episode was recorded in person at ACP’s (@ACPIMPhysicians) Internal Medicine Meeting 2023 #im2023 in San Diego.

Show Segments

• Intro
• Getting to know our guest
• Definition mono, dual, triple therapy, DAPT
• Post-PCI for NSTEMI with existing afib
• Stable CAD with new Afib
• CABG with New Afib
• Prior stent with New Afib
• Antiplatelet therapy after Acute Coronary Syndrome
• Primary Prevention
• Primary “and a half” Prevention
• Life’s Essential 8
• Outro

Antiplatelet, Anticoagulation Pearls

1. Monotherapy with a P2Y12 inhibitor (e.g. clopidogrel) might eventually replace aspirin for secondary prevention, especially for patients with high ischemic risk (expert opinion).
2. Individualize the duration of dual and triple therapy for patients with coronary disease, and atrial fibrillation based on ischemic, and bleeding risk.
3. Monotherapy with an oral anticoagulant can be used for patients with stable ischemic heart disease who develop atrial fibrillation (afib) —Knuuti, 2019.
4. Short-duration (1 to 3 months) dual antiplatelet therapy can be considered in select patients undergoing percutaneous intervention (PCI) followed by monotherapy with a P2Y12 inhibitor (Lawton, 2022).
5. Aspirin 100-325 mg is recommended after coronary artery bypass to reduce saphenous vein graft closure (Hillis, 2011, Lawton, 2022).
6. Know your P2Y12 inhibitors. Ticagrelor can cause dyspnea and/or bradyarrhythmia. Prasugrel should be avoided in patients with active bleeding, prior stroke, or age ≥75.
7. “Primary and a half” prevention with low-dose aspirin should be considered for patients with coronary artery calcium (CAC) score ≥100 (expert opinion).

Antiplatelet, Anticoagulation Show Notes

Definitions

• P2Y12 inhibitors (P2Y12i) include clopidogrel, prasugrel, and ticagrelor. P2Y12 is a receptor on platelets that binds adenosine 5’diphosphate (ADP) and plays a role in platelet function, hemostasis, and thrombosis (Cattaneo, 2015).
• Stable ischemic heart disease (AHA term) and chronic coronary syndrome (ESC term) refer to patients with known coronary disease and are at least 6-12 months from revascularization or an acute cardiac event
• Dual antiplatelet therapy (DAPT) = aspirin, plus a P2Y12i
• Anticoagulation = in this episode refers to oral anticoagulants with a preference for direct oral anticoagulants over vitamin K antagonists (Abadie, 2020)
• Monotherapy = use of a single agent (e.g. aspirin, a P2Y12i, or anticoagulation alone)
• Dual therapy = use of an antiplatelet (aspirin or a P2Y12i), plus anticoagulation
• Triple therapy = use of aspirin, plus a P2Y12i, plus anticoagulation

Know your P2Y12 inhibitors

Start here.