Indications for anticoagulant and antiplatelet combined therapy

Floyd, Christopher N.; Ferro, Albert

doi:10.1136/bmj.j3782

Cited by 30 publications

(28 citation statements)

References 9 publications

(11 reference statements)

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“…Our study pointed out that the most frequent combination was acetylsalicylic acid plus fluindione. Concerning acetylsalicylic acid, this is not surprising since this drug, according to current guidelines, should be prescribed as the first-line antiplatelet agent unless the patient is intolerant or has a compelling contra indication 19. It is important to point out that we did not check these last points in our study.…”

Section: Discussionmentioning

confidence: 90%

“…The novel P2Y12 inhibitors (prasugrel and ticagrelor) are currently reserved for patients with acute coronary syndrome, as they inhibit platelet activity to a greater extent than clopidogrel and so increase the risk of bleeding. The combination of novel P2Y12 inhibitors with oral anticoagulants increases the risk of bleeding and cannot consequently be recommended 19. For the anticoagulant, the preferential use of fluindione is very debatable.…”

Section: Discussionmentioning

confidence: 99%

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Anticoagulant and antiplatelet combined therapy in patients 75 years and over with atrial fibrillation: a prospective observational study assessing adherence to clinical guidelines

et al. 2018

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ObjectiveAccording to current guidelines on atrial fibrillation (AF), the addition of an antiplatelet therapy to an anticoagulant for a stable vascular disease does not decrease the ischaemic hazard but increases the risk of bleeding. The aim of the study was to assess compliance of practices with existing clinical guidelines concerning the use of anticoagulant-antiplatelet combined therapy in patients 75 years and over with AF.MethodsThis prospective observational study was carried out at the University Hospital of Strasbourg (France) between August 2016 and January 2017 with data collection on 1 day of every month. To be included, the patient had to be 75 years and over with AF and treated with anticoagulant-antiplatelet therapy. The population included all the patients admitted at the hospital excluding those from the Gynaecology-Obstetrics and Paediatrics departments. With regard to clinical ongoing guidelines (French, European, American and Canadian), the patients were sorted into three groups. Group 1: combined therapy in compliance with recommendations; Group 2: combined therapy debatable as to benefit-risk ratio; and Group 3: combined therapy not compliant with recommendations.ResultNinety-three out of 3307 patients 75 years and over received anticoagulant-antiplatelet combined therapy prior to their hospital admission. Thirty-two patients (34.4% – Group 1) had experienced an acute event and/or revascularisation within the past year. Twenty-four patients (25.8% – Group 2) had not experienced recent revascularisation and had stable coronary disease but were suffering from peripheral artery disease. Group 3 consisted of 37 patients (39.8%), none of which had experienced recent revascularisation or had unstable coronary disease. For all groups, the main dual therapy was acetylsalicylic acid + fluindione (59.1%).ConclusionIn our study, 37 antiplatelet (39.8%) treatments could have been stopped. These results should spur prescribers into regular reassessment of combination antithrombotic therapy since it contributes to polypharmacy and increases the risk of adverse events.

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Section: Discussionmentioning

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Anticoagulant and antiplatelet combined therapy in patients 75 years and over with atrial fibrillation: a prospective observational study assessing adherence to clinical guidelines

et al. 2018

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“…Warfarin requires routine blood monitoring, while DOACs do not. Only warfarin is recommended for the treatment of patients with valvular atrial fibrillation, defined as the presence of moderate-to-severe mitral stenosis or a mechanical heart valve [23,24]. The upfront cost of the two drugs is vastly different.…”

Section: Discussionmentioning

confidence: 99%

Trends in anticoagulant prescribing: a review of local policies in English primary care

Hove

Leng

2020

BMC Health Serv Res

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Background: Oral anticoagulants are prescribed for stroke prophylaxis in patients with atrial fibrillation, which is the most common heart arrhythmia worldwide. The vitamin K antagonist (VKA) warfarin is a long-established anticoagulant. However, newer direct oral anticoagulants (DOACs) have been recently introduced as an alternative. Given the prevalence of atrial fibrillation, anticoagulant choice has substantial clinical and financial implications for healthcare systems. In this study, we explore trends and geographic variation in anticoagulant prescribing in English primary care. Because national guidelines in England do not specify a first-line anticoagulant, we investigate the association between local policies and prescribing data. Methods: Primary care prescribing data of anticoagulants for all NHS practices from 2014 to 2019 in England was obtained from the ePACT2 database. Public formularies were accessed online to obtain local anticoagulation prescribing policies for 89.5% of clinical commissioning groups (CCGs). These were categorized according to their recommendations: no local policies, warfarin as first-line, or identification of a preferred DOAC (but not a preferred anticoagulant). Local policies were cross-tabulated with pooled prescribing data to measure the strength of association with Cramér's V. Results: Nationally, prescribing of DOACs increased from 9% of all anticoagulants in 2014 to 74% in 2019, while that of warfarin declined accordingly. Still, there was significant local variation. Across geographical regions, DOACs ranged from 53 to 99% of all anticoagulants. Most CCGs (73%) did not specify a first-line choice, and 16% recommended warfarin first line. Only 11% designated a preferred DOAC. Policies with a preferred DOAC indeed correlated with increased prescribing of that DOAC (Cramér's V = 0.25, 0.27, 0.38 for rivaroxaban, apixaban, edoxaban respectively). However, local policies showed a negligible relationship with the classes of anticoagulants prescribed-DOAC or VKA (Cramér's V = 0.01). Conclusions: Nationally, the use of DOACs to treat atrial fibrillation has increased rapidly. Despite this, significant geographical variation in uptake remains. This study provides insights on how local policies relate to this variation. Our findings suggest that, in the absence of a nationally recommended first-line anticoagulant, local prescribing policies may aid in deciding between individual DOACs, but not in adjudicating between DOACs and vitamin K antagonists (i.e. warfarin) as general classes.

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“…Combination of antiplatelet therapy and anti-thrombotic therapy is increasingly indicated given that AF and CAD commonly co-exist, and this adds additional complexity to the risk:benefit assessment. 19,20 This topic lies outside the scope of the ACC/AHA update, and although recommendations were made by the ESC update this has largely been superseded by a recent European consensus document that recommends use of the CHA 2 DS 2 -VASc and HAS-BLED scores when assessing risk:benefit ratio in AF, and a general preference for prescribing clopidogrel rather than prasugrel or ticagrelor. 21 In individuals with high atherothrombotic risk and low bleeding risk, triple therapy (aspirin, clopidogrel and oral anticoagulant) can be prescribed for up to 6 months, with dual therapy (clopidogrel plus oral anticoagulant) continued for up to 12 months after PCI.…”

Section: Combination Antiplatelet and Anti-thrombotic Therapymentioning

confidence: 99%

Dual Antiplatelet Therapy in Coronary Artery Disease: Comparison Between ACC/AHA 2016 and ESC 2017 Guidelines

Floyd

2020

Eur Cardiol

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Dual antiplatelet therapy (DAPT) is integral to the management of coronary artery disease (CAD) but there remains uncertainty as to the optimal approach for balancing an individual’s risk of atherothrombotic events versus their risk of bleeding complications. A myriad of clinical trials have investigated how factors such as antiplatelet selection or duration of treatment can affect outcomes in both stable CAD and acute coronary syndromes. To aid clinicians in the challenge of applying trial findings to the circumstances of individual patients, the American College of Cardiology/American Heart Association and European Society of Cardiology have released focused updates on prescribing DAPT in CAD. While the two guidelines agree on many issues, there are some differences in the recommendations. This article highlights those differences and provides comment on their aetiology.

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Indications for anticoagulant and antiplatelet combined therapy

Cited by 30 publications

References 9 publications

Anticoagulant and antiplatelet combined therapy in patients 75 years and over with atrial fibrillation: a prospective observational study assessing adherence to clinical guidelines

Anticoagulant and antiplatelet combined therapy in patients 75 years and over with atrial fibrillation: a prospective observational study assessing adherence to clinical guidelines

Trends in anticoagulant prescribing: a review of local policies in English primary care

Dual Antiplatelet Therapy in Coronary Artery Disease: Comparison Between ACC/AHA 2016 and ESC 2017 Guidelines

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