1. CV Update – Guidelines & Debates Royal Pharmaceutical Society, Great Britain Barnet – 27/01/09 Dr Ameet Bakhai, FRCP – Cardiologist, Clinical Trials, Health Economics Barnet & Chase Farm NHS Trust Royal Free NHS Trust, University of Hertfordshire Bushey Spire Conflict of Interest: Consultant to companies, Research Grants Work with NICE, AMORE Health, Health Smart UK

5. Atherothrombosis Significantly Shortens Life Expectancy (Prognosis) at 60 Framingham Heart Study Peeters et al. Eur Heart J 2002; 23: 458–466 HealthyHistory of Angina History of MI History of CVA 0 2 4 6 8 10 12 14 16 18 20 Years 9.27.412

11. www.nclcn.org.uk

13. Oral Anti-Platelet Therapy Maintenance for Cardiovascular Risk / Disease v2.0 Draft Produced by NCL CVD Prevention Task Group primary author Dr Ameet Bakhai- Review Date Jan 2010. NCL Cardiac and Stroke Network Ischaemic Stroke/TIA (no AF) Dipyridamole SR 200mg bd 2 years plus Aspirin 75mgs daily Or Aspirin 75mg daily (for patients intolerant to dipyridamole) Or Clopidogrel 75mgs daily for aspirin allergic patients Recurrent Strokes / TIAs (no AF) (whilst on aspirin and dipyridimole) No evidence base to provide guidance on changing to different anti-platelet agent ST elevation MI without stent Aspirin 75mg daily Clopidogrel 75mg daily 12 months* ST elevation MI with stent Aspirin 75mg daily Clopidogrel 75mg daily for 12 months* Non-ST elevation MI / Unstable angina with / without stent Aspirin 75mg daily Clopidogrel 75mg daily for 12 months* Chronic Stable Angina without recent event (>12 months) / Peripheral Arterial Disease Aspirin 75mg daily Drug Eluting Stent with / without MI Aspirin 75mg daily Clopidogrel 75mg daily for 12 months* Bare Metal Stent with / without MI / UA Aspirin 75mg daily Clopidogrel 75mg daily for 4 weeks* Patient on Aspirin with GI symptoms or previous ulcer with either age ≥ 60 or also using another anti-platelet / warfarin / corticosteroids/ NSAIDs / SSRIs should have PPI cover.^ Ensure medication is taken with food. Eradicate H Pylori as needed. Add Lansoprazole 30mg / Omeprazole 20mg daily (check outcome). Patient with a new gastro- intestinal bleed Discontinue aspirin and clopidogrel. Liaise with cardiologist and gastroenterologist urgently Aspirin Allergy (bronchospasm or angio-oedema) or rash, associated with administration of aspirin Clopidogrel 75mg Asymptomatic, Age≥50, 10 year CVD risk ≥20% Aspirin 75 mg daily after Baseline BP≤150 / 90 Asymptomatic with Diabetes Mellitus (I or II) with any of: Age≥40 / metabolic syndrome /≥10 year DM / HbA1c≥9% / Tchol ≥ 6mmol/l / on drugs for BP / organ damage / family history of premature coronary disease (M≤55, F≤65) Aspirin 75 mg daily after Baseline BP≤150 / 90 * In certain situations cardiologist may specify shorter or longer clopidogrel duration Primary Secondary When anti-platelet therapy is initiated in secondary care a clear written indication, which includes duration, should be recorded and communicated to primary care. Where a duration is NOT specified it is assumed the drug is to be continued long term. For complex patients not covered by these simplified guidelines - please contact the supervising consultant or Dr A Bakhai to assist. Ensure duration of therapy is flagged on GP’s clinical notes if NOT for long term. Recommend for clopidogrel – patients issued a clopidogrel patient card. For aspirin - enteric aspirin does not appear to confer advantage #.. References: NICE – Vascular Disease guidance TA090 NICE – NSTE -ACS guidance TA080 NICE – Post MI guidance (Mar 07) Joint British Society Guidance 2 (2005). Clopidogrel 12 mths – local consensus. ^Circulation 28.10.08 #National Prescribing Centre MeReC Bulletin 2005;15 Atrial fibrillation pts for antithrombotic but not for anticoagulants: warfarin Aspirin 75 mg daily after Baseline BP≤150 / 90

15. United Kingdom Clinical Pharmacy Association (cardiac group) Clopidogrel Patient Card http://www.ukcpa.org/?pid=0&lsid=3593&edname=22554.htm&ped=22554