Role of Atrial Fibrillation and Anticoagulants in ACS

Deepak L. Bhatt, MD, MPH: We should be clear to our audience. With atrial fibrillation, what’s the current standard of care in terms of antithrombotic therapy?

Vamsi Krishna, MD: Typically, first it’s determining if they need aspirin or not. And then we use the CHADS2-VASc score to help determine if we’re going to be placing them on either a vitamin K or non—vitamin K antagonist. And now there are some data for when we put stents in these types of patients, there are some strategies with apixaban and rivaroxaban for utilization of an antiplatelet and an antithrombotic.

Deepak L. Bhatt, MD, MPH: And edoxaban.

Vamsi Krishna, MD: Edoxaban, right, which is not much used in our clinical practice. I think all your points are absolutely correct. For primary care, they’re not going to know the procedure, angiographic characteristics, and a lot more patient-related characteristics. And there should be comfort level in saying, “Hey, we’re seeing this patient. We don’t necessarily need to have all the pieces of information,” especially 3 to 5 years out because the stent-related outcomes are dropping. You’re 1000% correct. I think in the endovascular interventional community, I’m trying to make us more aware of this communication gap.

Deepak L. Bhatt, MD, MPH: Yes, we must do better.

Vamsi Krishna, MD: It could be made quicker where we’re assessing that patient quickly and are able to at least say, “Hey, based on the information we have available today, this is a plan that we want to set in place.” And I think when I’m seeing all these patients it helps me, and I quickly look and say, “Oh yes, I wanted to use this strategy.” Going back to your pillars, the nonpharmacological therapy is also important. For example, there are a lot of data on if the patient eats 3 servings of vegetables and fruits, there’s an 18% reduction in MACE [major adverse cardiac events], as shown on a 20,000 patient study. So simple interventions and diet and exercise as well are very important, and I think in conjunction, what we were talking about can help reduce the risk.

Deepak L. Bhatt, MD, MPH: Yes, that’s an important point. Lifestyle, we often don’t emphasize it enough.

Manesh Patel, MD: Let me just say 1 thing, I agree with the notes. I think there is 1 thing that you highlighted about atrial fibrillation that I just want to make sure our audience is clear about, right? If atrial fibrillation is present, first you should decide if you’re going to anticoagulant the patient. I think these days with CHADS2-VASc score, you would say with a score of 2 or greater, most people are going to get anticoagulated.

The next thing you should do is say, “Do I need an antiplatelet?” I think we have now randomized data and other data observationally that would say, if they haven’t had a MI [myocardial infarction] recently—when I mean recently, I mean if they haven’t had an MI in the last year, certainly if they haven’t had an MI in the last 2 years—there’s no reason they have to be on that aspirin, and you’re going to reduce their bleeding risk.

So that’s number 1. Number 2 is, in your mind as a primary care physician or cardiologist or anyone, you should have a hierarchy of what you are treating. So if a patient has AFib [atrial fibrillation] and coronary stents and MI, I’m still treating the AFib. The patient with PAD [peripheral artery disease], CAD [coronary artery disease], and recent MI, I’m treating atherosclerosis. What’s the timeframe? For the patient with no known coronary disease or maybe atherosclerosis risk, I’m focusing on prevention because maybe there’s a risk continuum. I think one of the first steps is just to remember our pillars, but also our antiplatelet, antithrombotic therapy, and what we are treating. They have a VTE [venous thromboembolism] event. OK, I’m treating the VTE, I’m preventing the VTE. Now I’m done with that episode, I’m going back to preventing cardiovascular disease. It’s important with all these opportunities to think about our pyramid of therapy.

Deepak L. Bhatt, MD, MPH: Well it’s opportunities for enhancing care, or medical errors, that is, the dosing of a lot of these agents, the anticoagulants, would vary. Because with atrial fibrillation, we talked about full dose anticoagulation.

Transcript edited for clarity.