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Understanding Antiplatelets and Anticoagulants: Impact on Cardiac Patients by Dr. Jeremy Wright

Cardiologist Dr. Jeremy Wright from Hearts1st, Greenslopes Private Hospital, presents two clinical cases highlighting the importance of antiplatelet and anticoagulant medications in cardiac patients. The overview covers haemostasis, medication types, peri-procedural management strategies, and key considerations in patient care.

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Understanding Antiplatelets and Anticoagulants: Impact on Cardiac Patients by Dr. Jeremy Wright

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  1. Antiplatelets, AnticoagulantsWhat are the consequences Dr Jeremy Wright Cardiologist Hearts1st, Greenslopes Private Hospital

  2. Outline • 2 clinical cases • Overview of haemostasis • Antiplatelet medications • Anticoagulant medications • Strategy for peri-procedural management

  3. Case 1 • 86yo female • RCA stent 6 months ago • Hb 55, large colorectal cancer • Transfusion, staged anterior resection • Pre-op phone assessment advised stop Aspirin and Clopidogrel 1 week prior to surgery • Anterior resection performed • In recovery - chest pain and intermittent bradycardia

  4. Case 1 • Multiple VF arrests • Aspirated • Intubated • Angio showed stent thrombosis • IV heparin, eptifibatide • Prolonged stay in ICU • Discharged home 1 month later

  5. Case 2 • 83 yo female • 2 days post stent to LAD • Aspirin and Clopidogrel • Pleural effusion • Pleural tap requested to exclude empyema • Large haemothorax • Deceased despite resuscitation

  6. Haemostasis

  7. Haemostasis Antiplatelets Anticoagulants

  8. Antiplatelet medications • Aspirin • Cartia, Astrix, etc • Clopidogrel • Plavix, Iscover • Prasugrel • Effient • Ticagrelor • Brilinta • Fish Oil, Chinese Herbs • GP IIb/IIIa inhibitors – Reopro, Aggrastat

  9. Coronary Artery Stents • Three ‘Generations’ 1.) Bare Metal (BMS) 2.) Drug Eluting (DES) (first generation) 3.) Drug Eluting (DES) (second generation) • BMS require dual antiplatelet therapy for at least 1 month • DES require dual antiplatelet therapy for at least 6 months • Aspirin must continue

  10. Anticoagulants • Older agents • Oral: Warfarin • Injection: Heparin, Clexane, Danaparoid, Fondaparinux • New oral agents • Dabigatran (Pradaxa) • Rivaroxaban (Xarelto) • Apixaban (Eliquis) • New injection agents • Lepirudin (Refludan) • Bivalirudin (Angiomax) • Desirudin (Revasc)

  11. Time required for medications to wear off • Antiplatelets: 7 days • Warfarin: 5 days • Injections: 6-24 hours • New oral agents • Dabigatran (Pradaxa) 2 days if eGFR>50, otherwise 5 days • Rivaroxaban (Xarelto) 1-2 days • Apixaban (Eliquis) 1-2 days

  12. General Principles • Assess thromboembolic risk of stopping medication • Why taking the medication • How long ? • Previous bleeding problems • Assess bleeding risk associated with the procedure • Ultimate responsibility lies with the Dr performing the procedure, assisted by the referring Dr • Bridging medications may be required in some circumstances

  13. Confused? • CSANZ 2009 • Warfarin for prosthetic valves ?

  14. Confused? • Society of Interventional Radiology Consensus Guidelines • J Vasc Interv Radiol 2009; 20:S240-S249

  15. Take home messages • Critical to find out what the patient is taking – oral, SC, IV • There are many new medications • If not sure, look it up or ask • These decisions can be complex • Communication is the key

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