Dual antiplatelet therapy (DAPT) in the era of Novel Oral Anticoagulants (NOACs) SACIS 2015 Wesam A Alhejily MD FRCPC FACP FACC FSCAI Assistant Professor of Medicine Chief Of Adult Cardiology Consultant Cardiovascular Medicine and interventional Cardiology King Abdulaziz University Jeddah, Kingdom Of Saudi Arabia
Non Disclosures
Outlines Real Time Case Study Introduction to NOAC and NEW DAPT Review ACS trials of NOACS Recommendations for patients requiring OAC for Stroke prevention in afib (SPAF) and DAPT for acute coronary syndrome (ACS). Review evidence related to triple oral antithrombotic therapy (TOAT) Back to the case Summary and conclusion.
Mr WH 67 year old male ER visit May 2014 with worsening SOBOE x 2 weeks No chest pain, palpitations, syncope Presenting symptoms consistent with exacerbation of heart failure Cardiac risk factors: HTN, diabetes, dyslipidemia
Mr WH Past medical history HTN DM AVR 2009 (bioprosthetic) IHD PCI to LAD 2004 AV block Pacemaker 2013 OSA/ CPAP Atrial fibrillation Ablation 2008 Carotid endarterectomy Cancer Colon/ resected 2009 Medications prior to admission Dabigatran 110 mg BID Metoprolol 25 mg BID Atorvastatin 40 mg daily Amlodipine 7.5 mg daily Furosemide 60 mg daily NPH 60 units am and hs Aspart 10-15 units ac meals
Mr WH Course in hospital HF symptoms improved on IV furosemide ECHO FunctioningAortic valve, mild gradient LV function normal except septal/apical akinesis Angiogram RCA 99% (chronic) LAD (mid-third) 90% (de Novo) Cx 50% PCI culprit vessel (LAD) on May 22,2014, Eeverolomus (DES) stents
Question (s)? What should be done with anti platelet therapy and oral anticoagulation? Choices: ASA, clopidogrel, warfarin (Stop Dabigatran) Clopidogrel plus warfarin Dabigatran, clopidogrel, ASA For How long? Any other consideration?
Dual Antiplatelet therapy (DAPT)
NEW DAPT
Prasugrel
Ticagrelor
DAPT in ACS
DAPT post Stenting
NOVEL ORAL ANTICOAGULANTS
Why NOACs?
Mechanism Of Action
Metabolism
INDICATIONS
In non-valvular Afib
In DVT and PE
Other NOACS
Patients Follow up
Bleeding and need for reversal
Antidotes
NOAC(s) in ACUTE CORONARY SYNDROME
NOACS in ACS
NNT= 56 over 2 year
What did we learn from this Important observations from APPRAISE-2, ATLAS ACS-TIMI 46, and RUBY-1 suggest that in patients with a recent acute coronary syndrome, very low doses of an oral anticoagulant (Rivaroxiban) appear to be favorable.
Guidelines
Triple Therapy DAPT in addition to (N)OACs (Triple therapy)
Risk Assessment Ischemic Risk GRACE risk < 118 Low/moderate atherothrombotic risk GRACE risk >118 High residual atherothrombotic risk Stroke Risk CHADS VASC Bleeding HASBLED 3 Elevated bleed risk
HAS BLED SCORE
DUAL VERSUS TRIPLE
Pre NOAC (s)
Other questions? BMS VS DES, Shorter Duration of TT, GI protection
What about Triple Therapy (DAPT)+NOACS NO Study yet!
What s in the pipe?
As we Stand, NOAC and DAPT Efficacy evidence is lacking Bleeding risk is high!!! Definitions differ than that of SPAF Cannot compare ACS trials to SPAF Patient characteristics differ!! Doses in ACS trials differ from SPAF trials?
Back To Mr WH Triple therapy prescribed on discharge No dabigatran Warfarin, clopidogrel, ASA until August 2014 Target INR 2.0-2.5 Add PPI for GI protection. Warfarin plus ASA until May 2015 Resume dabigatran 150 mg bid (patient Preference) after one year.
In summary - Ideal combination of antiplatelet therapy and anticoagulants does not exist in patients with atrial fibrillation and a recent ACS. Needs to be individualized based on risks OAC plus clopidogrel? Risk Stratification is helpful!
Limit duration of TOAT to reduce risk of Bleeding Educate your patients on risks/benefits Provide GI protection May consider using bare metal stent over drug eluting stents.
REFERENCES 1)Asencio LA et al. Combining antiplatelet and antithrombotic therapy: what are the risks and benefits. American Journal of Medicine(article in press) 2014 2) Moser M et al. Triple antithrombotic therapy in cardiac patients:more questions than answers. European Heart Journal (2014) 35, 216 223 3) Mega JL et al. Rivaroxaban in Patients with a Recent Acute Coronary Syndrome. N Engl J Med 2012;366:9-19 4) Alexander JH et al. Apixaban with Antiplatelet Therapy after Acute Coronary Syndrome. N Engl J Med 2011;365:699-708 5) Tsu LE., Dager WE. Safety of New Oral Anticoagulants with Dual Antiplatelet Therapy in Patients with Acute Coronary Syndromes. Ann Pharmacother 2013;47:573-7 lation. Europace (2013) 15, 625 651
References 6) Dewilde WJ et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Published Online February 13, 2013 7) Cairns JA et al. Oral Antithrombotic Therapy in Atrial Fibrillation Associated With Acute or Chronic Coronary Artery Disease. Canadian Journal of Cardiology 29 (2013) S60-S70 8) Reed GW, Cannon CP Triple Oral Antithrombotic Therapy in Atrial Fibrillation and Coronary Artery Stenting. Clin. Cardiol. 36, 10, 585 594 (2013) 9) Menozzi M et al. Triple antithrombotic therapy in patients with atrial fibrillation undergoing coronary artery stenting: hovering among bleeding risk, thromboembolic events, and stent thrombosis. Thrombosis Journal 2012, 10:22 10) Heidbuchel H et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibril
Thanks