Antiplatelets VS Anticoagulants

Anti-platelets VS Anti-coagulants

Heart Failure Reduced Ejection Fraction in Sinus Rhythm

Anticoagulants

• reduce the risk of ischaemic stroke significantly.
• doubles the risk of major bleeding

Antiplateletes

• lower risk of major bleeding
• reduces the risk of ischaemic stroke

No significance in the incidence of patient mortality and hospitalisation

Cervical Artery Dissection

Nonvalvular Atrial Fibrillation

Combination of Antiplatelets & Anticoagulants

Antiocoagulants

Cornary and Peripheral Artery Disease

Atrial Fibrillation

No significant differences between treatment therapies

• directly associated with risk of gastrointestinal bleeding
• lower risk of intracranial haemorrhage

• low dose of Factor Xa inhibitor + Clopidogrel = benefit found
• full dose of Factor Xa inhibitor + PY12 antagonist = risk of major bleeding doubled

• combination resulted in significantly higher incidence rate of strokes and bleeding events
• does not reduce risk of experiencing acute coronary syndrome

Antiplatelets

Dermatologic Surgery

• higher risk of intracranial haemorrhage

• combination thrapy is not recommended
• increased risk of haemorrhage
• monotherapy recommended

Lower Gastrointestinal Bleeding

Antiplatelets

• higher incidence of re-bleeding

Antiplatelets

Anticoagulants

• no mortality rates in comparison to antiplatelets

TirT

Glycoprotein IIb/IIIa Inhibitors

Eptifibatide

Tirofiban

cyclic heptapeptide

non-peptide antagonist

PY12 Antagonist

Clopidogrel

Prasugrel

Ticagrelor

Other Antiplatelet Drugs

Dipyridamole

Aspirin

Triple Therapy

• Aspirin + Clopiddogrel + anticoagulant

> Why not Prasugrel?

• recommended in patients with AF undergoing PCI (percutaneous coronary intervention)
• risk of fatal and non-fatal bleeding increased more than 3-folds

Current Guideline Recommendations of Triple Therapy:

• duration of triple therapy should be as short as possible (up to 1 month)
• dual therapy; Clopidogrel + Anticoagulant preferred alternative
• single therapy of anticoagulant (lowest dose) required instead of VKA
• if VKA is needed, a lower target of INR 2.0-2.5 with sufficient time in therapeutic range

Antiplatelets Vs Anticoagulants

AMH 2020, Anticoagulants

https://amhonline.amh.net.au/chapters/blood-electrolytes/anticoagulants?menu=vertical

AMH 2020, Antiplatelets

https://amhonline.amh.net.au/chapters/blood-electrolytes/antiplatelet-drugs?menu=vertical

Douros A, Renoux C, Yin H, Filion KB, Suissa S, Azoulay L. Concomitant use of direct oral anticoagulants with antiplatelet agents and the risk of major bleeding in patients with nonvalvular atrial fibrillation. The American journal of medicine. 2019 Feb 1;132(2):191-9.

Fox KA, Velentgas P, Camm AJ, Bassand JP, Fitzmaurice DA, Gersh BJ, Goldhaber SZ, Goto S, Haas S, Misselwitz F, Pieper KS. Outcomes associated with oral anticoagulants plus antiplatelets in patients with newly diagnosed atrial fibrillation. JAMA network open. 2020 Feb 5;3(2):e200107-.

Gurbel PA, Fox KA, Tantry US, ten Cate H, Weitz JI. Combination antiplatelet and oral anticoagulant therapy in patients with coronary and peripheral artery disease: Focus on the COMPASS trial. Circulation. 2019 Apr 30;139(18):2170-85.

Hansen ML, Sørensen R, Clausen MT, Fog-Petersen ML, Raunsø J, Gadsbøll N, Gislason GH, Folke F, Andersen SS, Schramm TK, Abildstrøm SZ. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Archives of internal medicine. 2010 Sep 13;170(16):1433-41.

Iyengar S, Yeager DG, Cohen JL, Ozog DM. Update and Review of Bleeding Considerations in Dermatologic Surgery: Anticoagulants and Antiplatelets. Dermatologic Surgery. 2020 Feb 1;46(2):192-201.

Markus HS, Levi C, King A, Madigan J, Norris J. Antiplatelet therapy vs anticoagulation therapy in cervical artery dissection: the Cervical Artery Dissection in Stroke Study (CADISS) randomized clinical trial final results. JAMA neurology. 2019 Jun 1;76(6):657-64

Oakland K, Desborough MJ, Murphy MF, Schachter M, Jairath V. Rebleeding and mortality after lower gastrointestinal bleeding in patients taking antiplatelets or anticoagulants. Clinical Gastroenterology and Hepatology. 2019 Jun 1;17(7):1276-84.

Roule V, Ardouin P, Briet C, Lemaitre A, Bignon M, Sabatier R, Champ‐Rigot L, Milliez P, Blanchart K, Beygui F. Vitamin K antagonist vs direct oral anticoagulants with antiplatelet therapy in dual or triple therapy after percutaneous coronary intervention or acute coronary syndrome in atrial fibrillation: Meta‐analysis of randomized controlled trials. Clinical cardiology. 2019 Sep;42(9):839-46.

Saito Y, Kobayashi Y. Triple therapy: A review of antithrombotic treatment for patients with atrial fibrillation undergoing percutaneous coronary intervention. Journal of cardiology. 2019 Jan 1;73(1):1-6.

Sarafoff N, Martischnig A, Wealer J, Mayer K, Mehilli J, Sibbing D, Kastrati A. Triple therapy with aspirin, prasugrel, and vitamin K antagonists in patients with drug-eluting stent implantation and an indication for oral anticoagulation. Journal of the American College of Cardiology. 2013 May 21;61(20):2060-6.

Antiplatelets

inhibit platelet aggregation

prevent blood platelets from clumping together to form a clot

usually used in managing arterial thrombosis NOT in managing VTE (fibrin clots)

Anticoagulants

more specific mechanism of actiom

inactivate clotting factors IIa (thrombin) and XA

higher risk of adverse effects

Anti-coagulants

Other Anticoagulants

Warfarin

Vitamin K and Warfarin

• Vitamin K lowers INR values
• it is important the patient consumes the same amount of Vitamin K everyday
• Vitamin K helps the blood clot
• changes in Vitamin K levels need to be discussed with doctor

Heparins

Dalteparin

Danaparoid

Enoxaparin

Nadroparin

Heparin

Factors Xa Inhibitors

Apixaban

Fondaparinux

Rivaroxaban

Direct Thrombin Inhibitors

Bivalirudin

Argatroban

Dabigatran