Acute Coronary Syndrome: Why My Own Treatment Approach Has Changed

Douglas S. Paauw, MD

Disclosures

June 17, 2020

Anticoagulation in Patients With Acute Coronary Syndromes (ACSs)

For my patient in this scenario who is already on apixaban, I would recommend adding clopidogrel, which will decrease the risk for thrombosis in his brand new stent.

Results from a recent study have underscored my own change to now recommending dual therapy for my patients with AF who have experienced an ACS, whether treatment was medical or via a percutaneous coronary intervention (PCI).

AUGUSTUS, a randomized two-by-two factorial trial involving over 4600 patients with AF who had an ACS or had undergone PCI and were planning to take a P2Y12 inhibitor, sought to definitively answer the question as to the best anticoagulant therapy in this situation.

Patients were assigned to receive apixaban or warfarin and to receive aspirin or matching placebo for 6 months.

Some key findings should be noted:

  • The apixaban group experienced less bleeding (10.5% vs 14.7% in those receiving warfarin). The rate of major bleeding per 100 patient-years was highest with warfarin and aspirin (49.1), followed by apixaban and aspirin (33.6), warfarin and placebo (26.7), and apixaban and placebo (16.8).

  • The apixaban group also had less hospitalization and death than the warfarin group (23.5% vs 27.4%).

  • Rates of death or hospitalization and ischemic events were similar in the aspirin and placebo groups.

This was an extremely well-done study. I think it's changing our care and should reassure us when starting patients on a P2Y12 inhibitor, such as clopidogrel.

Bottom line: Apixaban is safer and has better outcomes than warfarin. Not to mention the added convenience for both patient and prescriber—no dietary restrictions, no need for repeated trips to anticoagulation clinics, and less worry about drug-drug interactions.

Aspirin just increases the risk for bleeding with no improvement in ischemic or mortality outcomes. Aspirin added to P2Y12 inhibitors and oral anticoagulants especially increases bleeding risks in our more elderly patients, the group that is also more likely to have poorer outcomes from bleeding.

Douglas S. Paauw, MD, is the Rathmann Family Foundation Endowed Chair in Patient-Centered Clinical Education and a professor of general internal medicine at the University of Washington. He was elected to Mastership in the American College of Physicians (ACP) in 2009. He is a frequent lecturer at the ACP annual meeting, presenting yearly standing-room-only lectures on drug interactions and medical myths.

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