2020 ACC Expert Consensus Pathway for Anticoagulant and Antiplatelet Therapy

Authors:
Kumbhani DJ, Cannon CP, Beavers CJ, et al.
Citation:
2020 ACC Expert Consensus Decision Pathway for Anticoagulant and Antiplatelet Therapy in Patients With Atrial Fibrillation or Venous Thromboembolism Undergoing Percutaneous Coronary Intervention or With Atherosclerotic Cardiovascular Disease: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2020;Dec 18:[Epub ahead of print].

The following are key points to remember from the 2020 ACC expert consensus decision pathway for anticoagulant and antiplatelet therapy in patients with atrial fibrillation (AF) or venous thromboembolism (VTE) undergoing percutaneous coronary intervention (PCI) or with atherosclerotic cardiovascular disease:

  1. Approximately 10% of patients with recent PCI have concomitant AF. Others may have concomitant VTE. Choosing the optimal antithrombotic regimen can be a challenge.
  2. Clinical pathways are suggested for four potential clinical situations: (1) prior AF on anticoagulation and the need for PCI; (2) new-onset AF requiring anticoagulation in a patient already on antiplatelet therapy for coronary artery disease (CAD); (3) prior VTE on anticoagulation and the need for PCI; and (4) new or recurrent VTE requiring anticoagulation in a patient already on antiplatelet therapy for CAD.
  3. In general, the use of “triple therapy” (dual antiplatelet therapy plus anticoagulation) is not recommended for most patients due to an increased risk of bleeding. If triple therapy is needed, a short duration (e.g., no more than 30 days) is recommended. When combined with an anticoagulant, clopidogrel is the recommended antiplatelet agent for most patients. If aspirin is being used, it should be limited to <100 mg daily dosing.
  4. For patients taking ≥2 antithrombotic agents, starting or continuing a proton pump inhibitor and avoiding other anti-inflammatory medications should be employed to reduce gastrointestinal bleeding risk.
  5. For patients with AF on anticoagulation who need a PCI, use of a direct oral anticoagulant (DOAC) is preferred over a vitamin K antagonist (VKA) when appropriate. Oral anticoagulation plus P2Y12 antiplatelet combination is recommended for the first 6-12 months (potentially switching P2Y12 to aspirin for months 6-12 if PCI for stable ischemic heart disease), followed by anticoagulation monotherapy after 12 months.
  6. For patients on antiplatelet therapy who develop new AF, management depends on the indication for antiplatelet therapy. For primary cardiovascular prevention, switch to anticoagulation monotherapy is recommended. For PCI with stable ischemic heart disease or acute coronary syndrome, use of oral anticoagulant plus a P2Y12 inhibitor for no more than 12 months is recommended, followed by oral anticoagulation alone. For patients with cerebrovascular disease without carotid stenting, oral anticoagulation monotherapy is recommended. For patients with carotid stenting or peripheral artery disease, a short course of anticoagulation plus P2Y12 inhibitor may be recommended, followed by oral anticoagulation alone.
  7. Management of patients with prior VTE depends on the clinical situation during which the VTE event occurred. If the VTE was associated with strongly provoking, reversible risk factors, then delaying a PCI may be beneficial so that anticoagulation therapy can be discontinued. If long-term/indefinite anticoagulation is required, then use of standard treatment doses of anticoagulation plus P2Y12 inhibitor antiplatelet therapy are recommended following PCI. If the dose of anticoagulation is reduced (e.g., “half-dose DOAC” for VTE secondary prevention), then continued use of a single antiplatelet medication (e.g., aspirin) is indicated long-term.
  8. For patients on antiplatelet therapy who develop a new VTE event, use of anticoagulation plus single antiplatelet medication is generally recommended. Patients using antiplatelet therapy for primary cardiovascular disease prevention or >12 months from the most recent PCI or acute coronary syndrome can be treated with anticoagulation monotherapy.
  9. For patients taking DOAC medications who require PCI, most DOACs can be held for no more than 36-48 hours prior to the procedure. Holding a DOAC for longer periods of time may be required for patients with moderate-severe renal dysfunction, especially if using dabigatran.
  10. When used in combination with antiplatelet medications, dosing of DOAC medications usually follows the Food and Drug Administration guidance for stroke prevention in AF or treatment of VTE. However, rivaroxaban may be administered at 15 mg daily (reduce to 10 mg daily for creatinine clearance <50 ml/min) when combined with P2Y12 inhibitors, based on the PIONEER-AF PCI study.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Cardiovascular Care Team, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, Anticoagulation Management and Venothromboembolism, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine, Chronic Angina

Keywords: Acute Coronary Syndrome, Angina, Stable, Angina, Unstable, Anticoagulants, Aspirin, Arrhythmias, Cardiac, Atherosclerosis, Atrial Fibrillation, Carotid Artery Diseases, Cerebrovascular Disorders, Coronary Artery Disease, Creatinine, Fibrinolytic Agents, Geriatrics, Hemorrhage, Myocardial Ischemia, Percutaneous Coronary Intervention, Peripheral Arterial Disease, Peripheral Vascular Diseases, Platelet Aggregation Inhibitors, Proton Pump Inhibitors, Pulmonary Embolism, Secondary Prevention, ST Elevation Myocardial Infarction, Stents, Therapeutics, Thromboembolism, Thrombosis, Vascular Diseases, Venous Thromboembolism, Venous Thrombosis, Vitamin K


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