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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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Some Extra Confusing Situations
1. AF + STABLE Coronary Artery Disease / Peripheral Arterial Disease
2. AF + PCI (elective) or AF + Acute Coronary Syndromes
STABLE = no PCI or ACS in preceding 12 months
Clarifying Confusing Terminology:
SAPT = Single Anti Platelet Therapy
DAPT = Dual Anti Platelet Therapy (ASA + P2Y inhibitor)
OAC = Oral anticoagulant
Dual Pathway Therapy = SAPT + OAC
Triple Therapy = DAPT + OAC
CCS 2020 AF Update
https://t.me/medicina_free
AF with
Vascular
Disease
(don’t worry,
we break it
down in next 4
slides)
CCS 2020 AF Update
https://t.me/medicina_free
(1) AFib + STABLE* CAD/PAD
CHADS65 = 0 à Single Antiplatelet
– “Consider” ASA + low dose rivaroxaban (2.5mg bid) per COMPASS trial
to reduce CV mortality
CHADS65 > 0 à OAC only
– Prefer DOAC > VKA
*STABLE CAD = no PCI or ACS in preceding 12 months
CCS 2020 AF Update
https://t.me/medicina_free
(2a) AFIB + PCI (elective or ACS)
Individualize based upon thrombotic risk
LOW RISK thrombotic events
Elective PCI (no ACS)
CHADS65 = 0 à DAPT
– DAPT for 6-12 months per CCS 2018
Antiplatelet Guidelines for non-AF patients
CHADS65 >0 à “Dual Pathway”
– SAPT with a P2Y inhibitor* + OAC for at
least 1 month, up to 12 months after PCI,
then OAC alone
HIGH RISK thrombotic events or
ACS with PCI
CHADS65 = 0 à DAPT
CHADS65 >0 à “Triple Therapy”x1-30d
THEN
“Dual Pathway Therapy” = clopidogrel + OAC up to 12
months post PCI
THEN
OAC only
*P2Y inhibitor = Pick CLOPIDOGREL – lower bleeding risk
CCS 2020 AF Update
**NEW** CCS 2023 Antiplatelet Guidelines says for PCI and need for OAC, dual pathway is recommended over triple
therapy but specifies they receive 1 dose of ASA with PCI. Therefore it is as if they had “1 day of triple therapy.” If asked in
an exam situation, minimizing triple therapy (1-30 days) or going straight to dual pathway would be guideline recommended
durations. Talking with the interventionalist would also be an important step (i.e. how complex was the PCI).
https://t.me/medicina_free
Who is HIGH RISK Post-Elective PCI?
Mitigate bleeding risk:
• Avoid prasugrel/ticagrelor
– that’s why they say
clopidogrel in guideline table
• Consider PPI
• Avoid other NSAIDs
• if VKA target INR 2-2.5
CCS 2020 AF Update
https://t.me/medicina_free
CHADS65 = 0 à DAPT = Dual Antiplatelet Therapy
(ASA + P2Y inhibitor)
CHADS65 > 0 à “Dual Pathway Therapy”: clopidogrel + OAC [apixaban1]
for 1 to 12 months post ACS
THEN
OAC only
1
TIP – the only OAC studied after ACS without PCI is apixaban 5mg po bid.
This is favoured in wording of guidelines for this scenario with clopidogrel.
CCS 2020 AF Update
(2a) AFIB + ACS – NO PCI /stent
Individualize based upon thrombotic risk
https://t.me/medicina_free
Prescribing notes – not all OAC the same dose
in dual pathway, triple therapy:
The OAC component of dual pathway regimens includes: normal dose edoxaban, apixaban, dabigatran
BUT rivaroxaban only 15 mg PO daily (10 mg in patients with CrCl 30-50 mL/min).
– A DOAC is preferred over warfarin, however if warfarin is to be used the lower end of the recommended INR
target range is preferred. All patients should receive a loading dose of ASA 160 mg at the time of PCI (if
previously ASA-naïve).
The OAC component of triple therapy regimens includes: warfarin daily, rivaroxaban 2.5 mg PO BID, or
apixaban 5 mg BID (reduced to 2.5 mg if they met two or more of the following dose reduction criteria:
age > 80 years of age, weight < 60 kg, or Cr > 133 μmol/L).
– A DOAC is preferred over warfarin, however if warfarin is to be used the recommended INR target is 2.0-2.5.
All patients should receive a loading dose of ASA 160 mg at the time of PCI (if previously ASA-naïve).
Thereafter, ASA may be discontinued as early as the day following PCI or it can be continued longer. The timing
of when to discontinue ASA will depend on individual patient’s ischemic and bleeding risk.
The dose of OAC beyond one year after PCI should be standard stroke prevention doses. A combination
of an OAC and single antiplatelet therapy may be used only in highly selected patients with high-risk
features for ischemic coronary outcomes, and who are also at low risk of bleeding
CCS 2020 AF Update
https://t.me/medicina_free
AF – OAC in Special Populations
CCS 2020 AF Update
Liver Disease
We recommend that OAC not be routinely prescribed in Child
-Pugh class C or liver
disease associated with significant coagulopathy
Cancer
Individualize OAC treatment in pts with active cancer. Consider DOAC> VKA.
Congenital Heart Disease
OAC for most patients with AF and HCM
OAC if CHADS65 risk factors
Frail Elderly
OAC
for most frail elderly – individualizing recommendations if high risk bleed
Secondary Atrial Fibrillation
=clearly provoked by transient/
reversible risk factor such as
severe sepsis, thyrotoxicosis
No OAC
Exceptions: patient’s underlying ‘abnormal substrate’ and risk for recurrence
estimated to be high and for “most patients during acute thyrotoxicosis until
euthyroid state is restored”
Pregnancy
(2021 CCS Pregnancy Heart
Disease Update)
No DOACs (cross placenta). Consider LMWH, Warfarin (Tri2
-3) in unique
circumstances (see OB Med lecture for more details).
Anticoag should be considered
for pregnant women with AF and (1) structural heart disease or (2) no structural heart
disease but CHADS >=1
High atrial events
(i.e. PACs)
WITHOUT AF
*NEW*
NOAH-AFNET6 trial looked at patients with mean CHA2DS2VASC 4 and high
atrial events (i.e. PACS) but no AF and started them on
edoxaban vs. placebo. NO
DIFFERENCE
in stroke/systemic embolism. Don’t start DOACs for PACS!
https://t.me/medicina_free
Cardio-
version
of AF
DOAC preferred
CCS 2020 AF Update
https://t.me/medicina_free
MCQ #4 2024
A 68yF is investigated for palpitations. She is a retired nurse and noticed that for the last
two years her HR is irregularly irregular. 48h Holter reveals she is in Afib throughout the
study, 95% of the time rates controlled <110bpm. She has a history of hypertension on
perindopril 8mg/indapamide 2.5mg, otherwise healthy, hates taking medications. Labs
are normal including TSH, LFTs, ECHO shows normal LV function with mild LVH and
enlarged LA, LAVI, mild MR. The sensation of irregular heart beat bothers her and she
would like treatment.
She is started on a DOAC for stroke prevention. What are the next best steps for this
patients symptoms?
a) Amiodarone oral load then 200 mg daily
b) Propafenone 150 mg po TID
c) Diltiazem CD 120 mg daily, and if still symptomatic book for elective cardioversion
d) Metoprolol 25 mg po BID, if symptoms persist start Dronedarone
https://t.me/medicina_free
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