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Anticoagulation? Antiplatelet?
What’s the Score?

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Copyright © 2015
 Issues for Mr. J

 Atrial fibrillation: thromboembolic risk

 Recent stent: stent thrombosis risk
 Triple oral anticoagulant therapy: bleeding risk

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 How do we determine stroke risk?

 CHADS2
 Congestive heart failure - 1pt
 Hypertension - 1pt
 Age > 75 - 1 pt
 Diabetes - 1pt
 Stroke or TIA - 2 pts

 0 points – low risk (1.2-3.0 strokes per 100 patient years)

 1-2 points – moderate risk (2.8-4.0 strokes per 100 patient years)
 > 3 points – high risk (5.9-18.2 strokes per 100 patient years)

*Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of Clinical Classification Schemes for
Predicting Stroke: Results From the National Registry of Atrial Fibrillation. JAMA. 2001;285(22):2864-2870.
You JJ, Singer DE, Howard PA, et al. Antithrombotic therapy for atrial fibrillation.
Chest. 2012;141(2_suppl):e531S-e575S.
Lip G, et al. Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism
in Atrial Fibrillation Using a Novel Risk Factor-Based Approach: The Euro Heart Survey on
Atrial Fibrillation. Chest. 2010;137(2):263-272.

CHA2DS2- VASc score = 4

Lip Y, et al. Refining Clinical Risk Stratification for Predicting Stroke and
Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based
Approach.Chest. 2010, 137(2):263.
 CHADS2 vs. CHA2DS2VASc

 CHADS2 score 0: 1.4% events

 CHA2DS2-VASc 0: 0 events

 CHA2DS2-VASc score 1: 0.6% events

 CHA2DS2-VASc score 2: 1.6% events
 CHA2DS2VASc score > 2= high risk

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*Lip G, et al. Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using
a Novel Risk Factor-Based Approach: The Euro Heart Survey on Atrial Fibrillation. Chest. 2010;137(2):263-272.
 Dual Antiplatelet Guideline

 Bare metal stent

 4-6 weeks, then ASA long term
 Drug eluting stent
 12 months, then ASA long term
 NSTEMI
 12 months
 STEMI
 12 months

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Our Approach to Chronic Atrial Fibrillation & Stenting

 Low stroke risk (CHADS2 0-1) + stent

 Dual antiplatelet therapy

 Moderate-high risk (CHADS2 >2) + stent

 Bare metal stent
 Warfarin + one month of dual antiplatelet therapy then:
 Warfarin + aspirin (low dose)
 Drug eluting stent
 Warfarin + 12 months dual antiplatelet therapy then
 Warfarin + aspirin (low dose)

 Novel oral anticoagulants not studied in this setting

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 Mr. J

 High risk embolic phenomena

 Continue warfarin
 BMS two weeks ago
 Continue aspirin long term

 Continue clopidogrel for another 2 weeks

and then discontinue (total duration dual
antiplatelet therapy 4 weeks)

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