Antithrombotic Therapy in Patients with Coronary Artery Disease and Prior Stroke

Abstract

Patients with coronary artery disease (CAD) and prior cerebrovascular events (CVE) are frequently faced in clinical practice and present a high rate of both ischemic and bleeding events. For these reasons, the antithrombotic management is particularly challenging in this subgroup of patients. Recent trials suggest that, although a potent antiplatelet strategy is safe in the acute phases of myocardial ischemia for these patients, the risk of major bleeding complications, including intracranial hemorrhage, is extremely high when the antithrombotic therapy is prolonged for a long period of time. Therefore, especially in patients with chronic CAD and history of CVE, the antithrombotic management should be carefully balanced between ischemic and bleeding risks. The present review is aimed at critically evaluating the available evidence to help make these crucial clinical decisions regarding the better antithrombotic therapy to use in this high-risk subgroup of patients.

Prevenção Farmacológica Secundária da Doença Arterial Coronariana em Pacientes Submetidos ao Manejo Clínico, Intervenção Coronária Percutânea ou Cirurgia de Revascularização Miocárdica

“…Embora vários agentes possam ser utilizados na terapia antitrombótica preventiva o sistema de saúde público brasileiro fornece apenas clopidogrel e ácido acetilsalicílico, o que reduz o desafio da seleção do medicamento. 23 O uso dos bloqueadores do SRAA e de betabloqueadores foi consistentemente abaixo de 50%, 14 o que foi comparável aos estudos com pacientes tratados com CABG no ensaio PREVENT IV 24 e na alta hospitalar após uma síndrome coronária aguda descrito em um estudo polonês. 22 Um estudo brasileiro com pacientes com DAC estável também mostrou baixas taxas de tratamento farmacológico ótimo, especialmente de bloqueadores do SRAA, mas detectou diferenças significativas de acordo com sexo e sistema de saúde (se público ou privado).…”

Efficacy and safety of two heparin regimens for prevention of venous thromboembolism in hospitalized patients with COVID-19: a meta-analysis

“…Overall, these results are not surprising. The concept that increasing anticoagulant effect results in bleeding is already known in many clinical scenarios as acute coronary syndromes, ischemic stroke and prophylaxis of VTE in medical patients [ 3 , 50 , 51 ]. Moreover, in patients admitted for COVID-19, those in the ICU setting have higher bleeding risks than those in the non-ICU setting [ 10 – 13 ].…”