Clot Chronicles: Antithrombotic Therapy in Patients with Afib or VTE Undergoing PCI

Hi, my name is Ty Gluckman. I am a noninvasive cardiologist and Medical Director of the Center for Cardiovascular Analytics, Research, and Data Science at the Providence Heart Institute at Providence St. Joseph Health in Portland, Oregon.

On this episode of Clot Chronicles, I will be discussing the recently published 2020 ACC Expert Consensus Decision Pathway for Anticoagulant and Antiplatelet Therapy in Patients with Atrial Fibrillation (Afib) or Venous Thromboembolism (VTE) undergoing Percutaneous Coronary Intervention (PCI) or with Atherosclerotic Cardiovascular Disease (ASCVD). This paper was recently published—in late December of 2020—and really was meant to help support clinicians in the challenging issue of what do you do with patients who may have varied indications for antithrombotic therapy. 

Specifically, we identified 4 key groups:

  1. A patient with Afib receiving an oral anticoagulant who now needs PCI and thus antiplatelet therapy.
  1. A patient on antiplatelet therapy for ASCVD with new-onset Afib that now requires an oral anticoagulant.
  1. A patient with prior VTE receiving anticoagulant therapy who now needs PCI and antiplatelet therapy. 
  1. And lastly, a patient on antiplatelet therapy for ASCVD with new VTE that requires an anticoagulant.

And the challenge for me—and the challenge I know for all of you—is how do we balance antiplatelet therapy indications with anticoagulation indications to arrive at the best possible antithrombotic combination in order to mitigate the risk of thrombotic events without engendering increased bleeding risk?

This is one of the key figures from the manuscript, but it really highlights the 4 scenarios that I just discussed and takes you through a stepwise process of reviewing clinical factors – what’s the condition that’s warranting anticoagulant therapy; the medication types (are they on an anticoagulant, are they on an antiplatelet therapy); and then, in some cases, their need for PCI. And we covered this from the perspective of those that are in the acute care setting, in the hospital, but also in the ambulatory setting, and then longer term, what should be doing post-discharge? 

There are a number of helpful figures that I’ll walk through briefly that really try and tee up a flow diagram or an algorithm to guide clinicians through the decision-making process. And while these look rather busy, in general, the themes are largely the same. As an example, this is the flow diagram for a patient with Afib on indefinite oral anticoagulation who now needs PCI. And importantly for this document, we reviewed this from the context of people who are on a vitamin K antagonist (VKA) or a direct oral anticoagulant (DOAC) and then ultimately walked people through the steps necessary to consider both pre-procedurally, post-procedurally, and then follow-up for longer-term discharge. 

We do a deeper dive in the hospital looking at people who are presenting based on the status of their PCI. Are they coming in for elective or urgent PCI? And in the case of elective PCI, can things potentially be postponed? In the case of emergent PCI, that’s not an option. And for people on a VKA or DOAC for preexisting Afib or VTE, how do you manage those anticoagulants? How do you manage antiplatelet therapy? Again, pre-cath-lab arrival, during the cath lab procedure, and then ultimately, in that early PCI period after they’ve completed their procedure transitioning to the discharge period.

This figure is actually the flip of that – what do you do for patients who are chronically on antiplatelet therapy who now come in with a diagnosis of Afib? So it walks people through an assessment of do they, in fact, have an indication for oral anticoagulant therapy? And if they do, what is the underlying driver of their indication for antiplatelet therapy? Was it being used previously for primary prevention? Do they have stable ischemic heart disease but no prior acute coronary syndrome? Do they have a history of acute coronary syndrome whether they’ve actually received PCI or not? Do they have a history of cerebrovascular disease, or do they have a history of peripheral arterial disease? And it walks people systematically through how to actually follow the transition from, in this case, someone who may have been on antiplatelet therapy that now may need to be combined with an oral anticoagulant therapy, or in fact, maybe someone can come off their antiplatelet therapy altogether and just remain on an oral anticoagulant alone.

We also come at this from a perspective of those who have had prior VTE. And while one may think that there is a lot of overlap—and, in fact, there is—there are unique differences for those individuals with VTE in so far as many of these individuals will not necessarily require indefinite oral anticoagulant or anticoagulant therapy. This breaks it down from the perspective of are they undergoing elective, urgent, or emergent PCI? And if so, how do you make decisions about initiation of anticoagulation overall? And then ultimately, if they have elective PCI and they have a time-limited duration of anticoagulation, can their elective PCI, in fact, be deferred altogether? 

We go a bit deeper in looking at people who have had VTE on a time-limited anticoagulant (on the top portion), those with VTE who now require indefinite anticoagulation and have undergone PCI (in the bottom), and really review this in great detail covering the various scenarios that you may come across in clinical practice. And lastly, for the patient that’s on antiplatelet therapy who now develops VTE, we have a parallel figure—very similar to that which we had for Afib—that walks individuals through the process of how you make decisions around combination antiplatelet and anticoagulate therapy. We further break this down (at the bottom) of whether or not those individuals had VTE associated with cancer or not associated with cancer, as the choice of anticoagulant and the duration may, in fact, differ in these populations.

So overall, while there are a lot of flow diagrams and the paper covers a lot of different topics, on behalf of all of my colleagues involved in the writing group, we very much hope that this type of document is useful in guiding clinicians in the outpatient setting and in the inpatient setting in figuring out the right combination of antiplatelet and anticoagulant therapy for the patients that you care for. Thank you so much. Hope this was helpful and please be safe. 

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