Clopidogrel, there is lack of data that could enable use of newer/other antiplatelet drugs.
The newer anticoagulants like dabigatran or rivoroxaban may hold a answer to this rather than changing over the antiplatelet drug...
To date, the best evidence based option is clopidogrel.
I usually prescribe triple therapy (aspirin, clopidogrel and VKA) for 1 month in case of BMS and 6 months in the case of DES or ACS setting (up to 12 month in patients with low bleeding risk and high thrombotic risk).
Single antiplatelet therapy plus VKA has been suggested and studied in WOEST trial (which was underpowered to test MACEs).
Prasugrel and ticagrelor have not been studied in patients treated with warfarin, since treatment with VKA was an exclusion criterion in TRITON-TIMI 38, ACCOAST and TRILOGY (for prasugrel) and in PLATO (for ticagrelor).
New interesting data about the use of new oral anticoagulant and P2Y12 inhibitors will come from PIONEER-AF study (NCT01830543), which is testing the use of rivaroxaban with different combinations of antiplatelets (including prasugrel and ticagrelor) in patients with AF undergoing PCI.
Clopidogrel should be preferred. Prasugrel and ticagrelor have not been studied yet in patients with warfarin. Optimal strategy in patients with non-valvular atrial fibrillation taking rivoraxaban or dabigatran who are scheculed for stent implantation, is cessation of these new oral anticoagulants and starting oral warfarine treatment in addition to aspirin plus clopidogrel.
Combination: warfarin (INR 2-2,5)+ aspirin 75mg+ clopidogrel 75mg and duration depend: type of the stent, stable or acute coronary syndromes, bleeding risk stratification, and tromboembolic and trombotic stratification.
Warfarin (INR 2-2,5 INR)+ ASA 75mg (100mg)+ clopidogrel 75mg and duration depend: type of the stent (BMS or DES), elective coronarography or acute coronary syndromes; bleeding risk stratification, and tromboembolic and trombotic stratification.
http://www.medscape.com/viewarticle/828336#3
Although underpowered for MACEs, WOEST is the only available randomized trial focused on the subject. Therefore, I adopt a VKA + single anti-platelet therapy with clopidogrel unless the patient is non-responder at verify-now test. In non-responders I add ASA.
In my experience I notice that the use of clopidogrel is safe and is also effective.
Given the results of the WOEST trial (despite relatively small size) triple therapy seems contraindicated as standard Rx when compared with clopidogrel/warfarin. The problem with the new anticoagulants instead of warfarin is that at therapeutic antiembolism doses bleeding risk with antiplatelets is very high (see NICE clinical guideline 172 update of secondary prevention of MI).
Generally, I agree with statements above. However, there are certain differences between coronary interventions that we should bear on mind. For example, there is a diference between a simple LAD stenting and complex left main lesion stented with two or even three stent. Therefore, in these "interventionally high-risk" pts I would prefere triple therapy for at least 1 month and then clopidogrel plus warfarin.
Dual antiplatelet therapy (Aspirin and clopidogrel) is currently the standard treatment after stent implantation. If warfarin is used concomitantly, the INR should be checked routinely, since the bleeding risk is high.
New data on this topic are available from ISAR TRIPLE study, which has been presented few days ago at TCT 2014.
How those new data impact on the decisions I must admit I am challenged to understand. Such a different approach to WOEST. Interesting they kept the aspirin - which I suspect is unnecessary if you are on a thienopyridine. Thanks very much for bringing this to our attention.
To my knowledge, the only P2Y12 inhibitor allowed in association with Warfarin is Clopidogrel. The duration of it's association with Warfarin and Aspirin after PCI depends on patient's HAS-BLED and CHA2DS2VASc score.
Assuming that most of the patients referred to elective PCI have a CHA2DS2VASc score ≥2, I usually prescribe triple therapy (Aspirin 100 mg, Clopidogrel 75 mg and Warfarin with INR range 2,0-2,5) for 4 weeks followed by double therapy (Clopidogrel and Warfarin) until the 12th month in patients at high bleeding risk. For patients at low bleeding risk I usually prolong the triple therapy until the 6th month and continue with double therapy until the 12th month. In both cases I prescribe Warfarin as single therapy lifelong.
- Badges
- Science topic
- Similar topics
- Medicine
- Disease
- Infectious Diseases