Society GuidelinesFocused 2012 Update of the Canadian Cardiovascular Society Guidelines for the Use of Antiplatelet Therapy
Section snippets
Optimal acetylsalicylic acid dose after ACS
An analysis of Clopidogrel in Unstable Angina to Prevent Recurrent Ischemic Events (CURE) provides insight into the optimal acetylsalicylic acid (ASA) dose after an ACS.3 There did not appear to be additional benefit for high-dose ASA in either the ASA alone group (highest dose [≥ 200 mg daily] vs lowest dose [≤ 100 mg daily]) or the ASA plus clopidogrel group.4 Conversely, major bleeding increased in a dose-dependent fashion in the ASA alone (1.9% low-dose, 2.8% medium-dose [>100 to < 200 mg
Optimal duration of dual antiplatelet therapy after stent implantation
The optimal dual antiplatelet therapy (DAPT) duration after drug-eluting stent (DES) placement remains controversial. A pooled analysis of randomized trials of patients free of major adverse cardiovascular events (MACEs) and major bleeding for ≥ 12 months after DES placement failed to show a significant benefit for an additional 12 months of DAPT with ASA and clopidogrel over ASA alone.20 In Prolonging Dual Antiplatelet Treatment After Grading Stent-Induced Intimal Hyperplasia Study (PRODIGY),
What Is the Optimal Antiplatelet Therapy Regimen After CABG?
Considered the gold standard for preventing saphenous vein graft closure after CABG, ASA is generally continued indefinitely because of its benefit in preventing subsequent clinical events.27, 28, 29 However, there is no published evidence suggesting antiplatelet therapy improves arterial graft patency. As summarized in the initial CCS guidance,1 low-dose ASA initiated 6 hours after surgery appears to maximize prevention of graft occlusion and minimize bleeding risk.30
The initial CCS guidance
Should Novel Oral Anticoagulants Be Used With Antiplatelet Agents for Secondary Prevention After ACS?
Patients with ACS remain at high risk for recurrent ischemic events despite significant advances in management. Considering the key role of platelet and coagulation factors in atherothrombosis, modern ACS treatment algorithms combine antithrombin and antiplatelet agents. Although an abundance of evidence demonstrates that prolonged antiplatelet therapy reduces recurrent events after ACS, data supporting long-term antiplatelet plus anticoagulant combination therapy are less convincing. Prolonged
Should PPIs Be Used in Patients Taking DAPT That Includes Clopidogrel?
Patients receiving clopidogrel, particularly as part of DAPT, are often prescribed PPIs for gastroprotection or acid suppression. Results from 2 meta-analyses and a large randomized clinical trial show that PPIs reduce the risk of upper gastrointestinal bleeding by ≥ 50% in this population.54, 55, 56 The effect of PPI and clopidogrel coadministration on ischemic events is less clear. Reports from several observational studies suggest concomitant PPI use might mitigate the beneficial effect of
Acknowledgements
The authors thank Sharon O'Doherty of the Thrombosis Interest Group of Canada and Kevin McKenzie of Lucid Consultancy for administrative assistance and Melanie Leiby, PhD, for editorial assistance.
Secondary Reviewers: Paul W. Armstrong, MD, FRCPC (University of Alberta, Edmonton, Alberta), David Fitchett, BChir, MD, MRCP, FRCP, FACC, FESC (University of Toronto and St. Michael's Hospital, Toronto, Ontario), Michael P. Love, MB, ChB, MD, MRCP (Queen Elizabeth II Health Sciences Centre, Halifax,
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The disclosure information of the authors and reviewers is available from the CCS on the following websites: www.ccs.ca and/or www.ccsguidelineprograms.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgement in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.