2018 Joint European consensus document: Mx of antithrombotic

Management of antithrombotic therapy in AF patients presenting with ACS and/or undergoing PCI

2018 Joint European consensus document


Since 2014 joint consensus document dealing with the management of antithrombotic therapy in atrial fibrillation (AF) patients presenting with acute coronary syndrome (ACS) and/or undergoing percutaneous coronary (PCI) or valve interventions, the approach to managing AF has evolved towards an integrated or holistic approach, with the three essential components of the patient management pathway {referred to as the ABC (Atrial fibrillation Better Care) pathway} as follows:

• ‘A’ Avoid stroke with Anticoagulation
• 
‘B’ Better symptom management, with patient centred decisions on rate or rhythm control
• 
‘C’ Cardiovascular and comorbidity risk management, including lifestyle changes

In recognizing these advances since the last consensus document, Task Force convened by EHRA (European Heart Rhythm Association), WG Thrombosis, EAPCI (European Association of Percutaneous Cardiovascular Interventions), and ACCA (European Association of Acute Cardiac Care), with additional contribution from Heart Rhythm Society (HRS), APHRS (Asia-Pacific Heart Rhythm Society), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA), has produced an updated consensus document, providing up-to-date consensus recommendations for use in clinical practice. The guidance document has been published in the journal EP Europace.

The consensus document includes recommendations on the following:-
1.    General management considerations 
2.    Elective or stable CAD 
3.    NSTE-ACS including unstable angina and NSTEMI 
4.    Primary PCI 

Some of the key recommendations are:-

A. General management considerations
• The period of triple antithrombotic therapy (TAT) should be as short as possible, followed by OAC plus a single antiplatelet agent [clopidogrel 75 mg once a day (o.d.), or alternatively, aspirin 75–100 mg o.d.]
• The duration of TAT is dependent on acute vs. elective procedures, bleeding risk (as assessed by the HAS-BLED score), as well as on type of stent (with a preference for new-generation drug eluting stent (DES) or bare metal stent (BMS))
• In AF patients, stroke risk must be assessed using the CHA2DS2-VASc score, and bleeding risk assessed using the HAS-BLED score
• Suboptimal stent placement should be avoided in selected cases by use of intracoronary imaging techniques
• An initial period of triple therapy should be used in most AF patients undergoing PCI, depending on presentation (ACS vs. elective), stroke vs. bleeding risk, and procedural considerations (e.g. stent type, disease severity etc.)
• Dual therapy with oral anticoagulant (OAC) plus one P2Y12 inhibitor (usually clopidogrel) may be considered in patients who are predisposed to excessive bleeding risk and have low thrombotic risk
• Dual therapy with rivaroxaban or dabigatran and a P2Y12 inhibitor is associated with a lower risk of bleeding than triple therapy with warfarin, but none have been sufficiently evaluated with respect to efficacy

B. Elective or stable coronary artery disease (CAD)
• For NOAC-treated pts undergoing elective PCI, timed cessation (e.g. >12-48 h) before intervention may be considered, depending on the agent and renal function and use of standard local anticoagulation practices peri-procedurally
• Early after PCI, such as the same evening or the next morning, NOAC Rx should be restarted
• In pts with stable CAD and AF undergoing PCI at low bleeding risk (HAS-BLED ≤2), triple therapy (OAC, aspirin 75–100 mg daily, clopidogrel 75 mg daily) should be given for a minimum of 4 weeks (and no longer than 6 months) after PCI following which dual therapy with OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day) should be continued for up to 6–12 months
• In patients with stable CAD and AF undergoing PCI at high bleeding risk (HAS-BLED ≥3), triple therapy [(N)OAC, aspirin 75–100 mg daily, and clopidogrel 75 mg daily] or dual therapy consisting of (N)OAC and clopidogrel 75 mg/day should be given for 1 month after PCI following which dual therapy with OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day) should be continued for up to 6 months, beyond which patients would be managed on (N)OAC alone
• In patients with stable CAD and AF undergoing PCI at very high bleeding risk(e.g. recent bleeding event), aspirin may be omitted, and dual therapy with a NOAC and clopidogrel 75 mg/day continued for 3-6 months, beyond which patients would be managed on (N)OAC alone

C. NSTE-ACS including unstable angina and NSTEMI
•  In patients on OAC developing a NSTE-ACS (Non-ST-Segment Elevation Acute Coronary Syndrome), aspirin loading should be as in STEMI, and clopidogrel is again the P2Y12 inhibitor of choice
•  Pre-treatment with P2Y12 receptor antagonists may be withheld until the time of coronary angiography in case of an early invasive strategy within 24 h
•  An early invasive strategy (within 24 h) should be preferred among AF patients with moderate to high-risk NSTE-ACS in order to expedite treatment allocation (medical vs. PCI vs. CABG) and to determine the optimal antithrombotic regimen
• The use of ticagrelor or prasugrel in combination with OAC may only be considered under certain circumstances (e.g. definite stent thrombosis while on clopidogrel, aspirin, and OAC; known clopidogrel resistance)
• Triple therapy is still the recommended initial treatment for the first month after PCI or an ACS in AF patients with a high-ischaemic risk and a low bleeding risk

D.  Primary PCI
• When anticoagulated patients present with a STEMI, they should be triaged for primary PCI regardless of the anticipated time to PCI-mediated reperfusion
• In the setting of STEMI, radial access for primary PCI is the best option to avoid procedural bleeding depending on operator expertise and preference
• In patients with STEMI and AF at low risk of bleeding (HAS-BLED 0–2), the initial use of triple therapy [(N)OAC, aspirin, and clopidogrel] should be considered for 6 months following PCI irrespective of stent type; this should be followed by long-term therapy (up to 12 months) with (N)OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75-100 mg/day)
• In patients with STEMI and AF at high risk of bleeding (HAS-BLED ≥3), the initial use of triple therapy [(N)OAC, aspirin, and clopidogrel] should be considered for 4 weeks following PCI irrespective of stent type; this should be followed by long-term therapy (up to 12 months) with (N)OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75-100 mg/day)
• In patients at very high bleeding risk (e.g. recent bleeding event), aspirin may be omitted, and dual therapy with a (N)OAC and clopidogrel 75 mg/day continued for 3-6 months, beyond which patients would be managed on (N)OAC alone

 

About EHRA
The European Heart Rhythm Association (EHRA) is a branch of the European Society of Cardiology (ESC). The leading network of European Cardiac Rhythm Management. It provides continuous education, training and certification to physicians and allied professionals involved in the field of cardiac arrhythmias with a special focus on Atrial Fibrillation (AF) and Electrophysiology (EP) and releases international consensus documents and position papers.

Note: This list is a brief compilation of some of the key recommendations included in the Guidelines and is not exhaustive and does not constitute medical advice. Kindly refer to the original publications here: https://pxmd.co/6aMUm (Executive Summary) https://pxmd.co/QvL6U (Consensus Statement)
 


About Author
Dr. Prachi Chhimwal
Dr. Prachi Chhimwal is an Editor at PlexusMD and is a part of the Engagment Team. She curates the Technical Content posted daily on the news feed. She graduated from Army College of Dental Sciences (B.D.S) and went on to pursue her post-graduation (M.D.S) in Oral & Maxillofacial Pathology. After a decade in the field of dentistry she took a leap of faith and joined PlexusMD. A badminton enthusiast, when not working you can find her reading, Netflixing or enjoying stand-up comedy shows.
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