ANTITHROMBOTIC TREATMENT IN PATIENTS WITH CONCOMITANT INDICATION FOR DAPT AND CHRONIC ORAL ANTICOAGULATION

ANTITHROMBOTIC TREATMENT IN PATIENTS WITH CONCOMITANT INDICATION FOR DAPT AND CHRONIC ORAL ANTICOAGULATION HUYNH TAN KHAO MD DISTRICT HOSPITAL 22/08/2019 Introduction • 6–8% of patients undergoing PCI have an indication for long-term oral anticoagulants (OACs) due to various conditions such as AF, mechanical heart valves, or venous thromboembolism • 5–8% of patients undergoing PCI have concomitant AF and an additional indication for oral anticoagulation (OAC) • The incidence of AF in patients with ACS ranges from 10% to 21% and increases with patient age and severity of myocardial infarction • Approximately 30% of patients with AF are found to have CAD, of whom up to 15% will require percutaneous coronary intervention (PCI) during their lifetime • Stroke rates are higher in patients with MI and AF than in those without AF (3.1% for those with AF versus 1.3% for those in sinus rhythm) • DAPT to OAC therapy results in at least a two- to threefold increase in bleeding complications 1.Eur Heart J 2017; 39(3): 213-60 N Engl J Med 2016;375:2423–34 Am Coll Cardiol 2013;61:2060–6 22/08/2019 4.Eur Heart J 2016;37:2893–962 Fig History of guideline recommendations for triple therapy vs dual therapy in patients with AF undergoing PCI 2010 (ESC) triple: VKA, aspirin, and clopidogrel in patients with AF undergoing PCI for as short a period as possible, which was based on expert opinions and not on RCTs Journal of Cardiology 2019 73, 1-6 Double Therapy in OAC Patients Undergoing PCI in the Era of Vitamin K Antagonists: WOEST and ISAR-TRIPLE 22/08/2019 1.Lancet 2013;381:1107–15 2.J Am Coll Cardiol 2015;65:1619–29 Fig History of guideline recommendations for triple therapy vs dual therapy in patients with AF undergoing PCI 2010 (ESC) triple: VKA, 2012 WOEST TRIAL 2012 WOEST TRIAL aspirin, and clopidogrel 2015 ISARTRIPLE 2014 AHA ACC in patients with AF 2015 ESC NSTEMI guidelines for AF undergoing PCI for as suggested considering Clopidogrel Safest short a period as dual antithrombotic P2Y12 inhibitors as a possible, which was treatment consisting of part of triple therapy based on expert OAC plus clopidogrel but because of the opinions and not on without aspirin as an lowest bleeding risk RCTs alternative to triple among the drugs therapy Class Iib, LOE: B 2016 AF ESC VKA rather than direct oral anticoagulant (DOAC) Journal of Cardiology 2019 73, 1-6 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation • Following coronary revascularization (percutaneous or surgical) in patients with AF and a CHA2DS2-VASc score of or greater, it may be reasonable to use clopidogrel (75 mg once daily) concurrently with oral anticoagulants but without aspirin (IIb Level of Evidence: B) • AF undergoing PCI ,†BMS may be considered to minimize the required duration of dual antiplatelet therapy Anticoagulation may be interrupted at the time of the procedure to reduce the risk of bleeding at the site of peripheral arterial puncture (IIa Level of Evidence: C) 22/08/2019 Antithrombotic strategies in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) and non-valvular atrial fibrillation European Heart Journal, Volume 37, Issue 3, 14 January 2016, Pages 267–315, https://doi.org/10.1093/eurheartj/ehv320 Double Therapy in OAC Patients Undergoing PCI in the Era of DOACs: PIONEER AF 22/08/2019 N Engl J Med 2016;375:2423–34 10 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS) 2018 ESC/EACTS Guidelines on myocardial revascularization European Heart Journal, Volume 39, Issue 3, 14 January 2018, Pages 213–260, https://doi.org/10.1093/eurheartj/ehy419 European Heart Journal, Volume 40, Issue 2, 07 January 2019, Pages 87–165, https://doi.org/10.1093/eurheartj/ehy394 2018 Management of antithrombotic therapy in AF patients presenting with ACS and/or undergoing PCI: A Summary of the Joint Consensus Document of the EHRA/APCI/ACCA/HRS/APHRS/LAHRS/CASSA Eur Heart J 2018;39(31):2847-2850 doi:10.1093/eurheartj/ehy396 Antithrombotic treatment in patients with concomitant indication for DAPT and chronic oral anticoagulation 22/08/2019 European Heart Journal, Volume 39, Issue 3, 14 January 2018, Pages 213–260, https://doi.org/10.1093/eurheartj/ehx419 17 2018 AHA Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention, Volume: 138, Issue: 5, Pages: 527-536, DOI: (10.1161/CIRCULATIONAHA.118.034722) 2018 AHA Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention, Volume: 138, Issue: 5, Pages: 527-536, DOI: (10.1161/CIRCULATIONAHA.118.034722) Figure 2018 Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report CHEST 2018 154, 1121-1201 DOI: (10.1016/j.chest.2018.07.040) Consensus Recommendations on the Practical Management of Oral Anticoagulation and Antiplatelet Therapy in Patients With AF Undergoing PCI 22/08/2019 21 2019 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation IIa IIa IIa IIa IIb 22/08/2019 B-NR If triple therapy (oral anticoagulant, aspirin, and P2Y 12 inhibitor) is prescribed for patients with AF at increased risk of stroke (based on CHA 2DS2-VASc risk score of or greater) who have undergone percutaneous coronary intervention (PCI) with stenting for ACS, it is reasonable to choose clopidogrel in preference to prasugrel B-R In patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of or greater) who have undergone PCI with stenting for ACS, double therapy with a P2Y 12 inhibitor (clopidogrel or ticagrelor) and dose-adjusted vitamin K antagonist is reasonable to reduce the risk of bleeding as compared with triple therapy B-R In patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of or greater) who have undergone PCI with stenting for ACS, double therapy with P2Y 12 inhibitors (clopidogrel) and low-dose rivaroxaban 15 mg daily is reasonable to reduce the risk of bleeding as compared with triple therapy B-R In patients with AF at increased risk of stroke (based on CHA2DS2-VASc risk score of or greater) who have undergone PCI with stenting for ACS, double therapy with a P2Y 12 inhibitor (clopidogrel) and dabigatran 150 mg twice daily is reasonable to reduce the risk of bleeding as compared with triple therapy B-R If triple therapy (oral anticoagulant, aspirin, and P2Y 12 inhibitor) is prescribed for patients with AF who are at increased risk of stroke (based on CHA2DS2-VASc risk score of or greater) and who have undergone PCI with stenting (drug eluting or bare metal) for ACS, a transition to double therapy (oral anticoagulant and P2Y12 inhibitor) at to weeks may be considered 22 P2Y12 INHIBITORS ? • Triple therapy showed that patients who received prasugrel instead of clopidogrel had a significant 3-fold increased risk of TIMI major or minor bleeding without differences in ischemic endpoints during months of follow-up despite small sample size • Patients with triple therapy are exposed to high bleeding risk, thus, using novel P2Y12 inhibitors (i.e prasugrel and ticagrelor) as a part of triple therapy is not recommended • 2015 ESC guidelines for non-ST segment elevation myocardial infarction (NSTEMI) indicated that prasugrel or ticagrelor as a part of triple therapy should be avoided due to the absence of safety and efficacy data (Class III, Level of Evidence: C) Clopidogrel may be the safest P2Y12 inhibitors as a part of triple therapy because of the lowest bleeding risk among the drugs • 2018 ESC guidelines on myocardial revascularization formally contraindicate the use of both prasugrel, ticagrelor in combination with OAC in Triple therapy (COR III, LOE C) • 2019 ACC/AHA/ HRS guidelines for AF recommend clopidogrel in TAT Combinations with COR IIa, LOE B Am Coll Cardiol 2013;61:2060–6 Capodanno, D et al J Am Coll Cardiol 2019;74(1):83–99 22/08/2019 23 Strategies to avoid bleeding complications in patients treated with oral anticoagulant • The safety of PCI on NOACs without additional parenteral anticoagulation is unknown, while no parenteral anticoagulation is needed if the international normalized ratio (INR) is > 2.5 in VKA-treated patients 22/08/2019 1.Eur Heart J 2017; 39(3): 213-60 Eur Heart J 2016 Jan 14;37(3):267-315 24 Ongoing clinical trials 22/08/2019 Y Saito, Y Kobayashi / Journal of Cardiology [vol_no] (2019) 1–6 25 Double Therapy in OAC Patients Undergoing PCI in the Era of DOACs: AUGUSTUS PCI 22/08/2019 N Engl J Med 2019;380: 1509–24 26 KEY POINTS Current guidelines recommendations of triple therapy for patients with AF undergoing PCI are as follows: • (1) the duration of triple therapy should be as short as possible (i.e for only peri-PCI period or up to month) based on patient ischemic and bleeding risks • (2) Dual therapy with clopidogrel plus OAC is an alternative to triple therapy in patients in whom the bleeding risk outweighs the ischemic risk • (3) DOAC with the lowest tested dose for stroke prevention may have to be used instead of VKA to avoid bleeding complications • (4) A lower target INR of 2.0–2.5 with sufficient time in the therapeutic range is needed if VKA is used (with the exception of patients with mechanical prosthetic valves in the mitral position) 22/08/2019 27 THANKS FOR YOUR ATTENTION! 22/08/2019 28 ... of patients undergoing PCI have concomitant AF and an additional indication for oral anticoagulation (OAC) • The incidence of AF in patients with ACS ranges from 10% to 21% and increases with. .. higher in patients with MI and AF than in those without AF (3.1% for those with AF versus 1.3% for those in sinus rhythm) • DAPT to OAC therapy results in at least a two- to threefold increase in. .. 2018;39(31):2847-2850 doi:10.1093/eurheartj/ehy396 Antithrombotic treatment in patients with concomitant indication for DAPT and chronic oral anticoagulation 22/08/2019 European Heart Journal,