ACC Issues Guidance on Antithrombotic Therapy

Debra L. Beck

December 23, 2020

The American College of Cardiology (ACC) has released a new Expert Consensus Decision Pathway (ECDP) on the use of anticoagulant and antiplatelet therapy in patients with atrial fibrillation (AF) or venous thromboembolism (VTE) undergoing percutaneous coronary intervention (PCI).

"It’s estimated that about 10%-15% of patients undergoing PCI have concomitant AF or VTE and need both anticoagulants and antiplatelets, so this is a very common clinical scenario," said committee chair Dharam J. Kumbhani, MD, from UT Southwestern Medical Center in Dallas, Texas.  

The document also provides guidance for clinicians on the use of antithrombotic outside the PCI setting in patients with atherosclerotic cardiovascular disease (ASCVD).

The Decision Pathway was published online December 18 in the Journal of the American College of Cardiology. 

Broadly speaking, the document also provides several decision pathway algorithms and is divided into four sections focused on specific clinical scenarios:

  • 1) a patient with AF on anticoagulant therapy who now needs a PCI and antiplatelet therapy;

  • 2) a patient on antiplatelet therapy with new-onset AF requiring an oral anticoagulant;

  • 3) a patient with prior VTE receiving an anticoagulant who now needs a PCI and antiplatelet therapy; and

  • 4) a patient on antiplatelet therapy for ASCVD with a new VTE requiring an anticoagulant

One thing that may surprise some clinicians, said Kumbhani, is that the authors have moved away from the use of triple antithrombotic therapy for most patients because of the increased risk of bleeding associated with it.

The addition of an antiplatelet agent to an oral anticoagulant increases the risk of bleeding by anywhere from 20% to as much as 60% and the addition of dual antiplatelet therapy to an oral anticoagulant "further increases the risk 2- to 3-fold," write the authors, a group that included at least two clinical pharmacists.

"As a rule, we're recommending dropping the aspirin and giving dual antithrombotic therapy consisting of an anticoagulant and a P2Y12 inhibitor for patients requiring both anticoagulant and antiplatelet therapy after recent PCI," Kumbhani told theheart.org | Medscape Cardiology.

The authors do leave room to consider triple therapy in select patients at high thrombotic risk, but stress it should be for the "shortest possible duration," for example, no more than 30 days after PCI. If aspirin is being used, it should be limited to less than 100 mg daily.

Another key recommendation, said Kumbhani, is that when combined with an anticoagulant, clopidogrel (Plavix) is the recommended antiplatelet agent for most patients.

"There is limited data for ticagrelor and prasugrel as part of a dual antithrombotic strategy, so I think the default P2Y12 inhibitors should really be clopidogrel," said Kumbhani.  

He also noted that, for patients with AF undergoing PCI, switching from warfarin (Coumadin) to a direct oral anticoagulant (DOAC) is recommended. "If you're going to put them on clopidogrel, it's pretty clear that bleeding risk is lowest with clopidogrel plus a DOAC compared with warfarin."

"There is an app coming out that will make the information we've synthesized and our treatment algorithms easy to access," he added. 

The work of the writing committee was supported exclusively by the ACC without commercial support. Kumbhani has disclosed no relevant financial relationships. Several members of the writing committee have disclosed relationships with industry; the full list can be found with the original article (Appendix 1)

J Am Coll Cardiol. 2020; Published online December 18, 2020. Full text

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