1. Anticoagulation? Antiplatelet? What’s the Score? COPYRIGHT © 2015, ALL RIGHTS RESERVED From the Publishers of

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3. Copyright © 2015 Dear Gurus: I need your help. My patient Mr. J is 78 years old and has chronic atrial fibrillation and hypertension. He receives warfarin to decrease the thromboembolic risk related to the atrial fibrillation. Two weeks ago he presented with unstable angina. There was no evidence of MI. He underwent coronary angiography and was found to have a 95% stenosis of the proximal LAD and no other coronary artery disease. PTCA was performed and a bare metal stent implanted. He was discharged taking warfarin + aspirin + clopidogrel. I saw him today and he is doing well. The question I have for you relates to his anticoagulant – antithrombotic therapy. I know that he requires the warfarin to decrease the risk of stroke related to atrial fibrillation and requires the dual antiplatelet therapy to decrease the risk of stent thrombosis. The triple anticoagulant – antiplatelet therapy though puts him at risk of bleeding. How would you sages handle this one? Joe Corncob Hospital Dear Gurus: I need your help. My patient Mr. J is 78 years old and has chronic atrial fibrillation and hypertension. He receives warfarin to decrease the thromboembolic risk related to the atrial fibrillation. Two weeks ago he presented with unstable angina. There was no evidence of MI. He underwent coronary angiography and was found to have a 95% stenosis of the proximal LAD and no other coronary artery disease. PTCA was performed and a bare metal stent implanted. He was discharged taking warfarin + aspirin + clopidogrel. I saw him today and he is doing well. The question I have for you relates to his anticoagulant – antithrombotic therapy. I know that he requires the warfarin to decrease the risk of stroke related to atrial fibrillation and requires the dual antiplatelet therapy to decrease the risk of stent thrombosis. The triple anticoagulant – antiplatelet therapy though puts him at risk of bleeding. How would you sages handle this one? Joe Corncob Hospital

4. Issues for Mr. J Atrial fibrillation: thromboembolic risk Recent stent: stent thrombosis risk Triple oral anticoagulant therapy: bleeding risk Copyright © 2015

5. How do we determine stroke risk? CHADS2  Congestive heart failure - 1pt  Hypertension - 1pt  Age > 75 - 1 pt  Diabetes - 1pt  Stroke or TIA - 2 pts  0 points – low risk (1.2-3.0 strokes per 100 patient years)  1-2 points – moderate risk (2.8-4.0 strokes per 100 patient years)  > 3 points – high risk (5.9-18.2 strokes per 100 patient years) *Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of Clinical Classification Schemes for Predicting Stroke: Results From the National Registry of Atrial Fibrillation. JAMA. 2001;285(22):2864-2870.

6. You JJ, Singer DE, Howard PA, et al. Antithrombotic therapy for atrial fibrillation. Chest. 2012;141(2_suppl):e531S-e575S.

7. Lip G, et al. Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based Approach: The Euro Heart Survey on Atrial Fibrillation. Chest. 2010;137(2):263-272. CHA 2 DS 2 - VASc score = 4

8. Lip Y, et al. Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based Approach.Chest. 2010, 137(2):263.

9. CHADS 2 vs. CHA 2 DS 2 VASc CHADS 2 score 0: 1.4% events CHA 2 DS 2 -VASc 0: 0 events CHA 2 DS 2 -VASc score 1: 0.6% events CHA 2 DS 2 -VASc score 2: 1.6% events CHA 2 DS 2 VASc score > 2= high risk Copyright © 2015

10. *Lip G, et al. Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based Approach: The Euro Heart Survey on Atrial Fibrillation. Chest. 2010;137(2):263-272.

11. Dual Antiplatelet Guideline Copyright © 2015 Bare metal stent  4-6 weeks, then ASA long term Drug eluting stent  12 months, then ASA long term NSTEMI  12 months STEMI  12 months

12. Our Approach to Chronic Atrial Fibrillation & Stenting Low stroke risk (CHADS 2 0-1) + stent  Dual antiplatelet therapy Moderate-high risk (CHADS 2 >2) + stent  Bare metal stent  Warfarin + one month of dual antiplatelet therapy then:  Warfarin + aspirin (low dose)  Drug eluting stent  Warfarin + 12 months dual antiplatelet therapy then  Warfarin + aspirin (low dose) Novel oral anticoagulants not studied in this setting Copyright © 2015

13. Mr. J Copyright © 2015 High risk embolic phenomena  Continue warfarin BMS two weeks ago  Continue aspirin long term  Continue clopidogrel for another 2 weeks and then discontinue (total duration dual antiplatelet therapy 4 weeks)

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