Dual Antithrombotic Therapy with Dabigatran after PCI in Atrial Fibrillation

Kevin Lao, Mercer University College of Pharmacy

The 2016 European Society of Cardiology guidelines recommend a short period of triple therapy (oral anticoagulant [OAC], aspirin, clopidogrel) for patients with atrial fibrillation (AFib) undergoing percutaneous coronary intervention (PCI) with a stent placement. [1]

Contrary to the European guidelines, the American Heart Association guidelines state that it may be reasonable to use clopidogrel with OAC without aspirin in AFib patients with CHA2DS2-VASc score ≥ 2 following PCI based on evidence that showed higher rates of bleeding with triple therapy. [2] Additionally, one previous trial has shown that dual therapy (warfarin + clopidogrel [P2Y12 inhibitor]) was associated with lower incidence of bleeding without increased rates of stent thrombosis in PCI patients compared to triple therapy. [3]

With the availability of the new oral anticoagulant (NOAC), some evidence suggests that NOAC, instead of warfarin, with a P2Y12 inhibitor (i.e. clopidogrel) may be an effective thromboprophylaxis in PCI patients. Therefore, the RE-DUAL PCI trial aimed to compare the efficacy and safety of dual therapy composed of dabigatran and P2Y12 inhibitor among patients with AFib undergoing PCI. [4]

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Rivaroxaban plus Aspirin for Stable Cardiovascular Disease?

Akpan Anani, Mercer University College of Pharmacy

Xarelto® (rivaroxaban) is an oral anticoagulant with indications for the treatment and prevention of thromboses, but not for the secondary prevention of cardiovascular events. [1] Conversely, aspirin has been shown to lower the risk of major adverse cardiovascular events and even cardiovascular death compared to placebo. [2] As a result, low dose aspirin (≤100 mg) is recommended for all tolerant patients in need of secondary prevention. [3] Due to bleeding risks, anticoagulants have not been recommended for these same patients. [4]

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EINSTEIN’s CHOICE for Treatment of Venous Thromboembolism

Dakota T. Craft, Mercer University College of Pharmacy

Venous thromboembolism (VTE) is a blood clot that starts in a vein and includes deep vein thrombosis (DVT) and pulmonary embolism (PE).  The development of VTE may be provoked or idiopathic in origin.  This condition can occur at any age, but is most common in adults over 60. [1]  A history of VTE is the main risk factor for recurrent VTE, with a risk of recurrence as high as 53% in 10 years. [2]

Goals of therapy include decreasing mortality and preventing thrombus embolization and recurrence.  Per the American College of Chest Physicians 2016 guidelines for the treatment of VTE, first line treatment options for VTE include dabigatran, rivaroxaban, apixaban or edoxaban, while vitamin K antagonists are second line.  Duration of therapy often depends on the patient’s calculated risk of recurrence, with some indications for indefinite anticoagulation treatment. [3]  Physicians may choose to treat with aspirin rather than anticoagulants after 6- 12 months due to concerns of bleeding. [4]
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