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P.37
CHAPTER 3
SECONDARY PREVENTION
AFTER ACS
3.1 GENERAL SECONDARY PREVENTION STRATEGIES
AND LIPID LOWERING ����������������������������������������������������� p.38
H. Bueno, S. Halvorsen
1- Acute care
• Drug therapy
• Coronary revascularisation
2- Cardiovascular risk assessment (e.g. concealed and uncontrolled risk factors)
3- Initiate secondary prevention and set treatment goals
Re-evaluate lifestyle, control of risk factors, psychosocial factors and adherance to therapy
Adjustment of secondary prevention therapies. Consider polypill, if needed
Reinforce education
Psychosocial support After 12 months Consider adding Consider Consider
consider*: Ezetimibe* dose adjustment SGLT2 inhibitor*
After Discharge Ticagrelor PCSK9 inhibitor* Consider ARNI* GLP-1 agonists*
60 mg bid
Anticoagulation?**
* When individually indicated and without specific contraindications. - ** Rivaroxaban 2.5 mg bid pending approval for indication in chronic CAD.
Reference modified from Cortés-Beringola A. Eur J Prev Cardiol 2017; 24(3 suppl): 22-28.
After ACS: POTENTIAL STRATEGIES
TO OPTIMIZE SECONDARY PREVENTION THERAPY 3.1
P.40
Reference: Valgimigli M, et al. Eur Heart J. 2018; 39:213-260. A = Aspirin C = Clopidogrel P = Prasugrel T = Tricagrelor
ANTITHROMBOTIC TREATMENT:
Dual antiplatelet therapy duration in patients with ACS (2) 3.2
P.42
CABG Medical Treatment Alone
12mo
A T or A T or A C
30mo AP AC
>12mo DAPT >12mo DAPT
Class IIb C Class IIb C
Reference: Valgimigli M, et al. Eur Heart J. 2018; 39:213-260. A = Aspirin C = Clopidogrel P = Prasugrel T = Tricagrelor
ANTITHROMBOTIC TREATMENT:
Switching between P2Y12 inhibitors for DAPT after ACS (1) 3.2
P.43
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dual therapy
STEP 1:
(e.g. NSAIDs or antiplatelets), alcohol abuse, ABC score: Age, Biomarkers (GDF-15, hs cTnT, Hb) and Clinical history of prior bleeding
• HIGH RISK OF RECURRENT CORONARY ISCHEMIC EVENTS? immediately after
ACS at presentation, prior ST, stenting of last remaining vessel, CrCL <60 ml/min, ≥3 stents implanted or lesions treated, stent implantation
bifurcation with 2 stents, overall stentlengh >60 mm, treatment of CTO clopidogrel should
be selected as
single antiplatelet
OAC: • NOAC* (preferable) agent. Aspirin
DUAL SAPT: • Clopidogrel 75 mg q.d. - Apixaban 5 mg b.i.d. (reduce to 2.5 mg b.i.d. (1) should however
THERAPY (preferable)* - Dabigatran 110 mg b.i.d. (preferable while on DAPT) be administered
Treatment type
BR>IR TRIPLE (for 1 mo.) DUAL (up to 12 mo.) OAC alone concomitant use
TRIPLE THERAPY strategy: of verapamil,
DUAL quinidine or
BR<IR TRIPLE (up to 6 mo.) (up to 12 mo.) OAC alone dronedarone.
(3)
CrCl 30-49 ml/min.
PRASUGREL PRASUGREL(2)
STOP
CLOPIDOGREL SURGERY CLOPIDOGREL
STOP
TICAGRELOR TICAGRELOR(2)
STOP
ASPIRIN(1)
//••••••9••••••8••••••7••••••6••••••5••••••4••••••3••••••2••••••1•••••• 0••••••••••••••••••1-4
a
Consider shortening DAPT duration or switching to less potent P2Y12 inhibitor (i.e. from ticagrelor/prasugrel to clopidogrel), especially if recurrent bleeding occurs
Reinitiate treatment within one week if clinically indicated. For Vitamin-K antagonist consider a target INR of 2.0-2.5 unless overriding indication (i.e. mechanical
b
heart valves or cardiac assist device) for NOAC consider the lowest effective dose. - c In case of triple therapy consider downgrading to dual therapy, preferably with
clopidogrel and OAC. - d If patients on dual therapy, consider stopping antiplatelet therapy if deemed safe.
Reference: Valgimigli et al. Eur Heart J.2018; 39:213-260.
ANTITHROMBOTIC TREATMENT:
Management of antiplatelet therapy after acute GI bleeding 3.2
P.49
Upper GI endoscopy demonstrates a nonvariceal source of bleeding (e.g. peptic ucler bleed)
High risk endoscopic stigmata identified Low risk endoscopic stigmata identified
(Forrest classification* Ia, Ib, IIa, IIb) (Forrest classification* IIc, III)
APT used for secondary prophylaxis APT used for secondary prophylaxis
(known cardiovascular disease) (known cardiovascular disease)
Patients on low dose ASA alone Patients on low dose ASA alone
• Resume low-lose ASA by day 3 following in dex endoscopy • Continue low-dose ASA without interruption
• Second-look endoscopy at the discretion
of the endoscopist may be considered Paptients on dual antiplatelet therapy (DAPT)
• Continue DAPT without interruption
Paptients on dual antiplatelet therapy (DAPT)
• Continue low dose ASA without interruption *The Forrest classification in defined as follows: Ia spuring
• Early cardiology consultation for recommendation hemorrhage, Ib oozing hemorrhage, IIa nonbleeding visible
of second resumption/ continuation of second APT vessel, IIb an adherent clot, IIc flat pigmented spot, and III clean
• Second-look endoscopy at the discretion of the base ucler.
endoscopoist may be considered
Reference: Halvorsen et al. Eur Heart J 2017; 38: 1455-62.
The ACCA
Clinical Decision Making
Toolkit is produced by the Acute Cardiovascular
Care Association (ACCA), developed and distributed
through an educational grant from AstraZeneca.
AstraZeneca was not involved in the development
of this publication and in no way influenced its content.