Download Antiplatelet medications

Antiplatelets, Anticoagulants
What are the consequences
Dr Jeremy Wright
Cardiologist
Hearts1st, Greenslopes Private Hospital
Outline
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2 clinical cases
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Overview of haemostasis
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Antiplatelet medications
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Anticoagulant medications
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Strategy for peri-procedural management
Case 1
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86yo female
RCA stent 6 months ago
Hb 55, large colorectal cancer
Transfusion, staged anterior resection
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Pre-op phone assessment advised stop Aspirin and
Clopidogrel 1 week prior to surgery
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Anterior resection performed
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In recovery - chest pain and intermittent bradycardia
Case 1
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Multiple VF arrests
Aspirated
Intubated
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Angio showed stent thrombosis
IV heparin, eptifibatide
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Prolonged stay in ICU
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Discharged home 1 month later
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Case 2
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83 yo female
2 days post stent to LAD
Aspirin and Clopidogrel
Pleural effusion
Pleural tap requested to exclude empyema
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Large haemothorax
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Deceased despite resuscitation
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Haemostasis
Haemostasis
Antiplatelets
Anticoagulants
Antiplatelet medications
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Aspirin
- Cartia, Astrix, etc
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Clopidogrel
- Plavix, Iscover
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Prasugrel
- Effient
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Ticagrelor
- Brilinta
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Fish Oil, Chinese Herbs
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GP IIb/IIIa inhibitors – Reopro, Aggrastat
Coronary Artery Stents
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Three ‘Generations’
1.) Bare Metal (BMS)
2.) Drug Eluting (DES) (first generation)
3.) Drug Eluting (DES) (second generation)
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BMS require dual antiplatelet therapy for at least 1 month
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DES require dual antiplatelet therapy for at least 6 months
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Aspirin must continue
Anticoagulants
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Older agents
- Oral: Warfarin
- Injection: Heparin, Clexane, Danaparoid, Fondaparinux
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New oral agents
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)
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New injection agents
- Lepirudin (Refludan)
- Bivalirudin (Angiomax)
- Desirudin (Revasc)
Time required for medications to wear off
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Antiplatelets: 7 days
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Warfarin: 5 days
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Injections: 6-24 hours
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New oral agents
- Dabigatran (Pradaxa) 2 days if eGFR>50, otherwise 5 days
- Rivaroxaban (Xarelto) 1-2 days
- Apixaban (Eliquis) 1-2 days
General Principles
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Assess thromboembolic risk of stopping medication
- Why taking the medication
- How long ?
- Previous bleeding problems
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Assess bleeding risk associated with the procedure
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Ultimate responsibility lies with the Dr performing the
procedure, assisted by the referring Dr
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Bridging medications may be required in some circumstances
Confused?
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CSANZ 2009
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Warfarin for prosthetic valves ?
Confused?
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Society of Interventional Radiology Consensus Guidelines
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J Vasc Interv Radiol 2009; 20:S240-S249
Take home messages
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Critical to find out what the patient is taking – oral, SC, IV
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There are many new medications
- If not sure, look it up or ask
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These decisions can be complex
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Communication is the key