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Concomitant Antiplatelet and OAC Tx : Real-World Practice

Concomitant Antiplatelet and OAC Tx : Real-World Practice. In the US, ~800,000 AF patients are on concomitant OAC and antiplatelet tx 1 Patients on chronic OAC with CAD are 7x more likely to receive concomitant antiplatelet tx 2

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Concomitant Antiplatelet and OAC Tx : Real-World Practice

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  1. Concomitant Antiplatelet and OAC Tx: Real-World Practice • In the US, ~800,000 AF patients are on concomitant OAC and antiplatelet tx1 • Patients on chronic OAC with CAD are 7x more likely to receive concomitant antiplatelet tx2 • Addition of single antiplatelet tx to OAC increases risk of major bleeding by >40%3 • Addition of doubleantiplatelettxto OAC increases risk of major bleeding by ~300%4,5 • Majority of studies evaluated warfarin; novel OACs may offer theoretical benefits in concomitant antiplatelet setting5,6 1Douketis JD. Thromb Res. 2011;127:513-517; 2Johnson SG. Chest. 2007;131:1500-1507; 3Dentali F. Arch Intern Med. 2007;167:117-124; 4Hansen ML. Arch Intern Med. 2010;170:1433-1441; 5Dans A. Circulation. 2012 Dec 27 [ePub ahead of print]; 6Sinnaeve PR. Circulation 2012 Dec 27 [ePub ahead of print]

  2. RE-LY: Main Results Study Design: PROBE (N = 18,113) Primary Efficacy: All stroke or systemic embolism Primary Safety: Major bleeding Mean Follow-up: 2 years Inclusion: NVAF and ≥ 1 risk factor* Mean CHADS2 Score: 2.1 (CHADS2 ≥3: 33%) Mean TTR: 64% *Risk factors: prior stroke/TIA; LVEF < 40%; NYHA Class ≥ II; aged ≥ 75 years, or aged 65-74 years with DM, HTN, or CAD †for both inferiority and superiority Connolly SJ, et al. N Engl J Med. 2009;361:1139-1151

  3. Effects of Adding Single or Dual Antiplatelet Tx on Major Bleeding in RE-LY • Regardless of OAC-type, addition of antiplatelet tx↑ bleeding risk • Single antiplatelet tx added to warfarin ↑bleeding risk by 60% • Adding dual antiplatelet tx to warfarin ↑bleeding risk by 230% • Dabigatran retained its benefit over warfarin in patients on antiplatelet tx Dans A, et al. Circulation. 2012 Dec 27 [ePub ahead of print]; Slide courtesy of Stuart J. Connolly, MD

  4. Recommendations for ConcomitantAntiplatelet + OAC Tx with Stent Placement: The North American Perspective BMS, bare-metal stent; DES, drug-eluting stent; OAC, oral anticoagulant (warfarin); SAPT, single antiplatelet therapy (aspirin or clopidogrel); ST, stent thrombosis; triple therapy (warfarin, aspirin, and clopidogrel) Faxon DP. CircCardiovascInterv. 2011;4:522-534

  5. Concomitant Antiplatelet and OAC Tx:Pearls for Practice • Txdecisions require careful balance of benefits vs inherent risks • Keep concomitant durations as short as possible • Use bare-metal stents, when possible • Lessen intensity of anticoagulation. • Target tighter INR for warfarin (target INR 2.0-2.5) • Lower doses of novel OACs • Lower doses of antiplatelet(s) • Consider prophylactic use of proton-pump inhibitors to reduce GI bleeding • Avoid concomitant NSAID use Faxon DP. CircCardiovascInterv. 2011;4:522-534

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