Ref- Blood June 2024
1. AUGUSTUS trial- use apixaban with plavix in Afib patients undergoing PCI or had ACS. OK to drop aspirin.
2. Define the indication for antithrombotic and or antiplatelet therapy and how the rx can change depending on the phase of rx.
3. If a pt is on aspirin for primary prophylaxis and develops a VTE--> stop aspirin, ct DOAC per existing guidelines i.e 3-6 months full dose, followed by maintenance if unprovoked. For such a pt recommend statins, weight loss and DM/HTN management.
4. Use PPI for GI prophy if DAPT of ir anticoagulant+ antiplatelet
5. Pt with hx of prior non embolic stroke on ASA develops PE--> stop ASA, switch to DOAC and ct
6. Recent MI, PCI, DES on DAPT, now with PE--> stop ASA, ct plavix, start DOAC if PCI was more than 30 days ago. DAPT plus DOAC only if very high risk of instent thrombosis typically first 30 days of DES. Typically stop all antiplatelets at 1 yr except high risk when it can be continued. ct DOAC at maintenance dose after 6 m.
7. Pt with peripheral arterial disease ( PAD) are at risk for limb loss and MI. If pt with PAD and hx of VTE on an anticoagulant now requires revascularization:
- ct anticoag alone if after surgical revasc
- anticoag plus aspirin 1-3 months after endovascular revasc
DPI- 2.5 mg BID eliquis plus ASA 81 mg
Stable CAD and symptomatic PAD after revas--> use DPI regimen
8. If PAD pt on DPI gets a VTE, up the DOAC to rx dose for 3 months if provoked, keep the ASA to overlap with Eliquis full dose for the first month after the VTE. The remaining 2 months keep only Eliquis 5 mg BID, then drop to 2.5 mg BID, restart aspirin. Use PPI.
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