The Anti coagulated Patient: The Cardiologist s View. February 28, 2015

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1 The Anti coagulated Patient: The Cardiologist s View February 28, 2015

2 Conflicts Dr. McMurtry has no conflicts to disclose.

3 CanMeds Medical Expert (as Medical Experts, physicians integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centered care. Medical Expert is the central physician Role in the CanMEDS framework.) Communicator (as Communicators, physicians effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.) Collaborator (as Collaborators, physicians effectively work within a healthcare team to achieve optimal patient care.) Manager (as Managers, physicians are integral participants in healthcare organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the healthcare system.) Health Advocate (as Health Advocates, physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.) Scholar (as Scholars, physicians demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge.) Professional (as Professionals, physicians are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.)

4 Overview: Risks for Withdrawing Antithrombotic Therapy Coronary Artery Disease Antiplatelet Drugs & Stents Atrial Fibrillation Oral Anticoagulants Prosthetic Heart Valves

5 Coronary Artery Disease Prevalence of coronary heart disease by age and sex (NHANES: ) Go A S et al. Circulation. 2014;129:e28-e292

6 Coronary Artery Disease Antithrombotic Medications: Aspirin (cyclooxygenase inhibitor) Clopidogrel (indirect P2Y 12 inhibitor) Ticagrelor (direct P2Y 12 inhibitor) Prasugrel (indirect P2Y 12 inhibitor) Choice depends on clinical indication

7 Coronary Artery Disease: NSTEACS We recommend ASA 81 mg daily indefinitely in all patients with NSTEACS (Strong Recommendation, High Quality Evidence). We recommend ticagrelor 90 mg twice daily over clopidogrel 75 mg daily for 12 months in addition to ASA 81 mg daily in patients with moderate to high risk NSTEACS managed with either PCI, CABG surgery, or medical therapy alone (Strong Recommendation, High Quality Evidence). We recommend clopidogrel 75 mg once daily for 12 months in addition to ASA 81 mg daily in patients with NSTEACS managed with either PCI, CABG, or medical therapy and who are not eligible for ticagrelor or prasugrel (Strong Recommendation, High Quality Evidence). Tanguey JF et al. Can J Card. 2013;29:

8 Coronary Artery Disease: STEMI We recommend clopidogrel 75 mg daily for at least 1 month in addition to ASA 81 mg daily in patients with STEMI who were managed with either fibrinolytic therapy or no reperfusion therapy (Strong Recommendation, High Quality Evidence). We suggest that clopidogrel can be continued for 12 months (Conditional Recommendation, Low Quality Evidence). We recommend either prasugrel 10 mg daily or ticagrelor 90 mg twice daily over clopidogrel 75 mg daily for 12 months in addition to ASA 81 mg daily after primary PCI (Strong Recommendation, Moderate Quality Evidence). We recommend clopidogrel 75 mg daily for 12 months in addition to ASA 81 mg daily after primary PCI in patients who are not eligible for prasugrel or ticagrelor (Strong Recommendation, Moderate Quality Evidence). Tanguey JF et al. Can J Card. 2013;29:

9 Coronary Artery Disease: Elective PCI We recommend that in patients receiving a bare metal stent who are unable to tolerate clopidogrel for 12 months (eg, increased risk of bleeding or scheduled noncardiac surgery), the minimum duration of therapy should be 1 month (Strong Recommendation, High Quality Evidence). We suggest in patients at very high risk of bleeding, the minimum duration of treatment may be 2 weeks (Conditional Recommendation, Low Quality Evidence). We suggest that in patients receiving a second generation DES who are unable to tolerate clopidogrel for 12 months (eg, increased risk of bleeding or scheduled noncardiac surgery), the minimum duration of therapy may be 3 months (Conditional Recommendation, Low Quality Evidence). Tanguey JF et al. Can J Card. 2013;29:

10 Withdrawing Dual Antiplatelet Therapy Cassese S et al. European Heart Journal (2012) 33,

11 Withdrawing Dual Antiplatelet Therapy Cassese S et al. European Heart Journal (2012) 33,

12 Withdrawing Dual Antiplatelet Therapy Cassese S et al. European Heart Journal (2012) 33,

13 Withdrawing Dual Antiplatelet Therapy Cassese S et al. European Heart Journal (2012) 33,

14 Withdrawing Dual Antiplatelet Therapy Mehran R et al. Lancet 2013; 382:

15 Withdrawing Dual Antiplatelet Therapy Mehran R et al. Lancet 2013; 382:

16 Withdrawing Dual Antiplatelet Therapy Mehran R et al. Lancet 2013; 382:

17 Withdrawing Dual Antiplatelet Therapy Mehran R et al. Lancet 2013; 382:

18 Withdrawing Dual Antiplatelet Therapy Hawn MT et al. JAMA. 2013;310(14):

19 Withdrawing Dual Antiplatelet Therapy Hawn MT et al. JAMA. 2013;310(14):

20 Withdrawing Dual Antiplatelet Therapy Hawn MT et al. JAMA. 2013;310(14):

21 Withdrawing Dual Antiplatelet Therapy Hawn MT et al. JAMA. 2013;310(14):

22 Coronary Artery Disease > 1 year post MI/PCI, dual antiplatelet therapy can be safely stopped Within the first month post PCI, disruption of dual antiplatelet therapy has risk, and the risk is highest in the first week * Brief interruption (<14 days) of dual antiplatelet therapy after the first month is associated with minimal ischemic risk * Brief interruption of antithrombotic therapy > 6 months post ACS appears safe * *based on observational data

23 Atrial Fibrillation Current and Future Prevalence Projections for Atrial Fibrillation Lifetime risk for Atrial Fibrillation Mozzaffarian et al. Circulation Epub ahead of print.

24 Non Valvular Atrial Fibrillation We recommend that OAC therapy be prescribed for most patients aged 65 years or CHADS 2 score 1. We recommend that when OAC therapy is indicated for patients with nonvalvular AF, most patients should receive dabigatran, rivaroxaban, apixaban, or edoxaban (when approved) in preference to warfarin (Strong Recommendation, High Quality Evidence). Verma A et al. Can J Card. 30 (2014) 1114e1130

25 Atrial Fibrillation Sherwood MW et al. Circulation. 2014;129:

26 Atrial Fibrillation Sherwood MW et al. Circulation. 2014;129:

27 Atrial Fibrillation Sherwood MW et al. Circulation. 2014;129:

28 Atrial Fibrillation Sherwood MW et al. Circulation. 2014;129:

29 Atrial Fibrillation Sherwood MW et al. Circulation. 2014;129:

30 Atrial Fibrillation Sherwood MW et al. Circulation. 2014;129:

31 Atrial Fibrillation Sherwood MW et al. Circulation. 2014;129:

32 Non Valvular Atrial Fibrillation Temporary interruptions in oral anticoagulation are associated with small but real risks for stroke and systemic embolism. The risk is likely less than 0.5% at 30 days for most patients * It is not known whether bridging is safe or effective *based on observational data

33 Prosthetic Heart Valves Prevalence of heart valve lesions Mozzaffarian et al. Circulation Epub ahead of print.

34 Prosthetic Heart Valves Daniels et al. Thrombosis Research 124 (2009)

35 Prosthetic Heart Valves Daniels et al. Thrombosis Research 124 (2009)

36 Prosthetic Heart Valves Daniels et al. Thrombosis Research 124 (2009)

37 Prosthetic Heart Valves Temporary interruption is oral anticoagulation for patients with mechanical valves is associated with small but real thromboembolic risk, likely less than 1% * at 3 months Bridging might have a role for selected patients, but randomized trials are needed *based on observational data

38 Thank you!

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