The following are key points to remember about managing antithrombotic therapy in elderly patients with coronary artery disease (CAD):

1. Elderly patients (>65 years old) have increased risk of both ischemic and bleeding events. A favorable risk-benefit profile should be maintained.
2. Aspirin, an irreversible cyclooxygenase-1 inhibitor, is the mainstay of secondary prevention of CAD and ischemic events.
3. P2Y12 inhibitors include clopidogrel, prasugrel, and ticagrelor:
   • Clopidogrel, the most widely used, has a high level of interpatient variability.
   • Prasugrel provides more predictable platelet inhibition. In elderly patients with acute coronary syndrome (ACS), it reduces risk of ischemic events more than clopidogrel but is associated with increased risk of major bleeding.
   • Ticagrelor also reduces risk of ischemic events without significantly increasing major bleeding, regardless of age. Dyspnea is a common side effect.
4. For patients with ACS with or without percutaneous coronary intervention (PCI), prasugrel or ticagrelor are preferred over clopidogrel.
5. For PCI with chronic coronary syndrome, clopidogrel is the only approved P2Y12 inhibitor.
6. Prasugrel is generally not recommended for patients >75 years of age except in high-risk patients without other contraindications. The 5 mg dose of prasugrel is preferred in elderly patients versus the 10 mg dose.
7. Vitamin K antagonist anticoagulation and rivaroxaban are also options for secondary prevention of ischemic outcomes. Both are associated with increased bleeding. Rivaroxaban 2.5 mg twice daily with aspirin is approved for patients of all ages with chronic CAD or peripheral artery disease.
8. The following strategies can reduce risk of bleeding in elderly patients:
   • In patients with ACS, an initial decision to treat with ticagrelor, prasugrel, or clopidogrel should be based on risk scores and qualitative assessment. Ticagrelor is a reasonable option in non-frail, non-high-bleeding risk elderly patients without contraindications and with no other factors associated with bleeding not included in risk scores. Efficacy of 5 mg prasugrel is similar to ticagrelor but with reduced bleeding.
   • At 30 days after ACS, consider change from more-potent to less-potent P2Y12 inhibitor.
   • In patients treated with ticagrelor, consider discontinuing aspirin 3 months following PCI or ACS event.
   • Following newer-generation drug-eluting stent, consider decreasing dual antiplatelet therapy duration to 3-6 months in elderly patients (instead of 12 months) or 1-3 months following PCI with chronic CAD.
   • In patients requiring oral anticoagulation (OAC) post-PCI, employ a strategy of P2Y12 inhibitor with OAC without aspirin.
   • Use the shortest possible duration of dual antiplatelet therapy in patients who require OAC.
9. At 12 months following ACS and/or PCI, aspirin remains the cornerstone of antiplatelet therapy. Other strategies can be considered, such as monotherapy with P2Y12.
10. Other measures to minimize bleeding in patients undergoing PCI include radial access, proton pump inhibitors, avoidance of nonsteroidal anti-inflammatory drugs, control of other risk factors, and close follow-up.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Anticoagulation Management and ACS, Interventions and ACS, Interventions and Coronary Artery Disease

Keywords: Coronary Artery Disease, Aged, Fibrinolytic Agents, Platelet Aggregation Inhibitors, Purinergic P2Y Receptor Antagonists, Aspirin, Anticoagulants, Acute Coronary Syndrome, Percutaneous Coronary Intervention, Risk Factors, Secondary Prevention

< Back to Listings