Scenario

A normally well 76-year-old lady had an NSTEMI 2 years ago and had successful stenting with a drug eluting stent (DES) for a severe left anterior descending artery narrowing. She had residual mild diffuse disease elsewhere.

After 12 months of dual antiplatelet therapy with Aspirin and Ticagrelor, she is now on Aspirin, in addition to Atorvastatin 40mg and Cilazapril 2.5mg for hypertension.

When seen in clinic, she reported no angina but was found to have new incidental asymptomatic atrial fibrillation. She had no history of stroke or TIA.

The best strategy for managing her stroke risk is

1) Aspirin alone

2) Aspirin plus Warfarin

3) Aspirin plus Dabigatran

4) Warfarin alone

5) Dabigatran alone

Discussion

Her CHA2DS2VASC score is high at 5 indicating an annual stroke risk of 6.7%. She will require anticoagulation.

The more conclusive evidence of Aspirin is after an ACS and certainly in the first 6-12 months after a DES.

The combination of Aspirin and oral anticoagulation (Warfarin or newer novel oral anticoagulant) increases the risk of bleeding (especially gastrointestinal) without additional vascular benefit.

The aspirin could be stopped and oral anticoagulation started. If a novel oral anticoagulant is chosen, one needs to be cautious with the usual contraindications, including advanced age and renal function.

Author

Dr Seif El-Jack

Scenario:

A 75-year-old male is now 7-month post anterior myocardial infarction. He had successful proximal LAD drug eluting stent, currently on Aspirin and Ticagrelor. He is awaiting total hip joint replacement, and the orthopaedic surgeon would like to know whether he could stop his anti-platelets.

Thinopyridines in combination with Aspirin should in general continue for:

At least 12 months after ACS – Stent (DES or BMS) or No Stent
1 month after BMS (Bare Metal Stent) in stable CAD
6 – 12 months after DES (Drug Eluting Stent) in stable CAD – some recent evidence that the duration can be shortened to 3 months in special circumstances with modern stents (after discussion with cardiologist)

Dual antiplatelet therapy interruption

Whether to discontinue depends on: type of surgery, comfort level of the surgeon, time from the index stent procedure, type of stent used and vessel treated.

General guide for stopping dual anti-platelet prior to non-cardiac surgery:

Aspirin not to be stopped
Clopidogrel 5 days prior to surgery
Ticagrelor 5 days prior to surgery
Prasugrel 7 days prior to surgery

The key point here is that there is much variation between individual patients, depending on both the cardiac and non-cardiac issues. Cardiologists should be consulted before stopping such therapy so that we could come up with the best solution for the individual patient.

In the scenario above, how we deal with the Ticagrelor around the time of hip surgery would most likely depend on the technical aspects of the STEMI and stent implantation, as well as the urgency of the hip surgery.

Author:

Dr Ali Khan