Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians EvidenceBased Clinical

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• Antithrombotic and Thrombolytic Therapy American
  College of Chest Physicians Evidence-Based
  Clinical Practice Guidelines (8th Edition)
• Anticoagulation in Coronary Artery disease
• or can your blood ever really be too thin?
• ACC Noon Conference
• Jason Haag

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Antithrombotic and Thrombolytic Therapy ACCP
Guidelines

• Parenteral anticoagulants
• Perioperative management of antithrombotic
  therapy
• Treatment and prevention of heparin-induced
  thrombocytopenia
• Prevention of VTE
• Antithrombotic therapy for venous thromboembolic
  disease
• Antithrombotic therapy in AF
• Valvular and structural heart disease
• Antithrombotic therapy and thrombolytic therapy
  for ischemic stroke

• Antithrombotic therapy for non-ST-segment acute
  coronary syndromes Acute ST-elevation myocardial
  infarction
• Primary and secondary prevention of chronic
  coronary artery disease
• Antithrombotic therapy in peripheral artery
  occlusive disease
• VTE, thrombophilia, antithrombotic therapy, and
  pregnancy
• Antithrombotic therapy in children and neonates

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Anticoagulation
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Case 1

• 64 y.o. AAM with HTN, DM admitted to cardiology
  service with substernal chest pressure occurring
  at rest and relieved with nitro. Vital signs
  stable. Physical exam unremarkable. Cardiac
  biomarkers negative.
• EKG shows the following

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Case 1
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Case 1

• Cardiac biomarkers cycles are remain negative
• Patient goes for cardiac catheterization the
  following morning which shows the following

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Case 1
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Case 1

• A bare metal stent is placed in the LAD lesion
  with resolution of symptoms. Patient asks Hey
  Doc, I already take a baby aspirin a day. Do I
  need to take anything else to keep my blood
  thin?
• Anticoagulation
• What drugs and for how long?
• What if a drug eluting stent had been placed
  instead?
• How about just POBA (angioplasty)?

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Case 1 ACS with PCI /- Stenting
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Case 1 ACS with PCI /- Stenting
Causes for controversy While BMS will rarely
thrombose after 1 month, DES may thrombose months
to years after implantation making
discontinuation of clopidogrel a tricky venture.
Small survival benefit to clopidogrel therapy in
DES noted up to 2 years out.
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Case 2

• 65 y.o. WM with history of CAD s/p NSTEMI 4
  months ago with successful implantation of DES
  presents for routine follow up. Pt has been
  extremely debilitated since his MI and spends
  most of his days lying in bed watching Dr. Phil.
  Vitals are wnl, but exam reveals unilateral
  swelling of his left lower extremity.
• PVL demonstrate the following

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Case 2
Normal
Pt
Doppler
Compression
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Case 2

• You break the great news that your patient now
  has a deep vein thrombosis and explain that he
  will have to begin anticoagulation therapy for
  his DVT. Doc, Im already on Plavix and
  aspirin, how thin does my blood really need to
  be?
• How do you manage this patients anticoagulation?
• Can you stop the aspirin or plavix?
• What if the patient had another indication for
  VKA such as mechanical valves, atrial
  fibrillation
• Would you feel more or less likely to withhold
  VKA therapy or antiplatelet therapy?

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Case 2 The Triple Cocktail
Controversy evidence is fairly poor (Grade 2C)
and most studies are retrospective metanalysis.
Catch 22 - findings shows increased risk of CVA
with withholding VKA in patients with indication
and already on ASA/Clopidogrel and increased risk
of stent thrombosis for patients on VKA/ASA
withholding clopidogrel, both groups have
statistically significant increase in bleeding
complications Ways to minimize risk of bleeding
placement of BMS in ACS/NSTEMI/STEMI to shorten
duration of clopidogrel therapy. What about
GIIb/IIIa inhibitor?
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Case 3

• A 55 y.o. WF with a history of DM presents for
  new patient visit.
• 2 months earlier she presented to an OSH with
  atypical chest pain (sharp, right sided,
  pleuritic occurring at rest and with exertion).
  She underwent an adenosine MIBI which showed an
  inferior perfusion defect and underwent
  catheterization with placement of a DES for an
  isolated 70 distal RCA lesion.
• She was subsequently started on ASA and
  clopidogrel.
• Today the patient feels fine except for
  occasional palpitations. No h/o heart failure,
  CVA.

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Case 3
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Case 3 The Afib Dilemma
CHADS2 stroke risk index assigns 1 point for each
of four risk factors (congestive heart failure,
hypertension, age gt 75 years, diabetes mellitus)
and 2 points for a previous stroke. Score 0-1
recommend ASA, Score 2-3 recommend VKA gtgt
ASA Score gt3 recommend VKA
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Case 3 The Afib Dilemma

• To anticoagulate or not to anticoagulate that is
  the question?
• Does being on ASA and clopidogrel influence your
  decision?
• What if the patient had HTN as well?
• If TTE shows normal sized left atrium
• Rate vs. Rhythm control revisited?

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Case 3 The Afib Dilemma
Same recommendations as before, but requires
more thought. Unlike DVT or mechanical valve
anticoagulation with atrial fibrillation there
are other options namely aspirin.
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Case 4

• 50 y.o. obese WM with history of HTN, HLD,
  tobacco abuse presents for new patient
  appointment. Pt states that his father passed
  away from an MI at age 40. He is an extremely
  compliant patient and adheres to his medical
  regiment which includes aspirin. He asks, Doc,
  is this little 81 mg aspirin enough to keep my
  blood thin?

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Case 4 ASA vs. VKA Primary prevention
Thrombosis Prevention Trial - men aged 45-69
with no ischemic heart disease, but in top 20 of
risk distribution based on smoking, family
history, BMI, BP, Chol, plasma fibrinogen level,
Factor VII activity - 2,540 people in trial,
showed a reduction in fatal MIs in the VKA over
ASA - However, overall IHD ARR (VKA) 2.6
events/1000 person years vs. (ASA) 2.3
events/1000 person years - Questions define
high risk, long term compliance
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Case 5

• 65 y.o. AAM with history of DM, HTN, HLD presents
  for routine follow up. Today he notes that he
  is having increasing cramping in his legs with
  exercise. The cramping is relieved with rest.
• Being no fan of the kidney, you order an
  arteriogram that shows the following.

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Case 5
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Case 5

• You explain to the patient that they have
  longstanding peripheral vascular disease.
  Unwilling to undergo potential stenting or bypass
  of his lower extremities the patient asks if
  there might be a medication he could take. So
  you place him on cilostazol.
• The patient presents to your office the next
  month for follow up. While in the waiting room
  he acutely becomes pale, diaphoretic and
  complaining of substernal chest pressure. EKG
  shows the following.

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Case 5
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Case 5

• He is rushed to the cath lab which demonstrates.

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Case 6

• Thanks to your quick work your patient survives
  his STEMI and underwent successful BMS placement
  to his occluded RCA. After the procedure the
  patient asks you if he really needs to be on this
  new expensive blood thinning medication called
  clopidogrel. After all, hes already on aspirin
  and cilostazol.
• Can he come off of the clopidogrel?

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Case 6 The Vasculopath
Not as intuitive as you might think. Cilostazol
has both antiplatelet and vasodilatory effects.
Several small studies initially showed prevention
of restenosis with cilostazol, however larger
trial proved clopidogrel superior. Studies
have shown increased stent diameter with triple
antiplatelet therapy (ASA, clopidogrel and
cilostazol vs. ASA and clopidogrel alone.
However, not very clinically useful.
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References

• Becker, R, Meade, T, Berger, P, et al. American
  College of Chest Physicians Evidence-Based
  Clinical Practice Guidelines (8th Edition) The
  Primary and Secondary Prevention of Coronary
  Artery Disease. CHEST 2008 133 776-814S
• Goodman, S, Menon, V, Cannon, C, et al. American
  College of Chest Physicians Evidence-Based
  Clinical Practice Guidelines (8th Edition) Acute
  ST-Segment Elevation Myocardial Infarction.
  CHEST 2008 133 708-775S
• Harrington, R, Becker, R, Cannon, C, et al.
  American College of Chest Physicians
  Evidence-Based Clinical Practice Guidelines (8th
  Edition) Antithrombic Therapy for Non-ST-Segment
  Elevation Acute Coronary Syndromes. CHEST 2008
  133 670S-707S
• Kessler, C. Anticoagulation and thrombolytic
  therapy. Practical Considerations. CHEST 1989
  95 245-256S