In general the patients are elderly people. I prefer to use rivaroxaban, but the risk of bleeding is high. Do you have other choice?
in the acute stage , you can use aspirin + Plavix + warfarin
after 1 months , use plavix +warfarin
Did you mean AF (afib) patients? My answer assumes you did. In these patients i would advocate going for a bare metal stent and limit Plavix to one month. However, if they already have a DES, you will have to use full dose Asa for a month along with Plavix. I would decrease Asa to 81mg QD right after 1 month and limit Plavix to a year. I would leave them on life-long low dose Asa and coumadin or anti-Xa inhibitors as long as AF is present. The risk of bleeding is higher with age and triple therapy, so choose Eliquis (Apixaban) which in comparison to Coumadin had lower bleeding risk. However no head to head comparison of the Xa inhibitors has been performed to date.
Triple antithrombotic therapy in AF patients who received DES is reserved only for ASA + clopidogrel + warfarin. The use of novel oral anticoagulants (NOAC) (rivaroxaban, dabigatran, etc) in such a clinical scenario is contraindicated due to an extremely high risk of bleeding. NOAC doses that protect against thromboembolic events in AF (rivaroxaban 20mg, dabigatran 150mg and 110mg) are too high for a triple antithrombotic combination (please see ATLAS ACS TIMI 46 and REDEEM trials).
EMA has approved rivaroxaban for a triple antithrombotic therapy in acute coronary syndromes, but rivaroxaban doses are much lower - 2.5mg BID) - FDA has not approved rivaroxaban in that indication.
agree with Dr Hudzik, we should at least be targeted by the evidence. This particular condition should take into account the associated dual antiplatelet therapy with warfarin becomes effective control of thrombotic complications and also enables support in the clinical complications when there is a need to abort the effect of warfarin. The classic example is fracture of neck of femur in the elderly.
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