Focused 2012 Update of the Canadian Cardiovascular Society Guidelines for the Use of Antiplatelet Therapy

doi:10.1016/j.cjca.2013.07.001

Canadian Journal of Cardiology

Volume 29, Issue 11, November 2013, Pages 1334-1345

https://doi.org/10.1016/j.cjca.2013.07.001 Get rights and content

Abstract

The initial 2010 Canadian Cardiovascular Society (CCS) Guidelines for the Use of Antiplatelet Therapy in the Outpatient Setting were published in May 2011. As part of a planned re-evaluation within 2 years, we conducted an extensive literature search encompassing all topics included in the 2010 CCS Guidelines, and concluded that there were sufficient new data to merit revisiting the guidance on antiplatelet therapy for secondary prevention in the first year after acute coronary syndrome (ACS), percutaneous coronary intervention, or coronary artery bypass grafting, and the interaction between clopidogrel and proton pump inhibitors. In addition, new clinical trials information about the efficacy and safety of combining novel oral anticoagulants with antiplatelet therapy in ACS justified the addition of a new section of recommendations to the Guidelines. In this focused update, we provide recommendations for the use of clopidogrel, ticagrelor, and prasugrel in non-ST elevation ACS, avoidance of prasugrel in patients with previous stroke/transient ischemic attack, higher doses of clopidogrel (j) /day) for the first 6 days after ACS, and the preferential use of prasugrel or ticagrelor after percutaneous coronary intervention in ACS. For non-ACS stented patients, we recommend acetylsalicylic acid/clopidogrel for 1 year, with at least 1 month of therapy for bare-metal stent patients and 3 months for drug-eluting stent patients unable to tolerate year-long double therapy. We also consider therapy for patients with a history of stent thrombosis, the indications for longer-term treatment, discontinuation timing preoperatively, indications for changing agents, the management of antiplatelet therapy before and after bypass surgery, and use/selection of proton pump inhibitors along with antiplatelet agents.

Résumé

Les Lignes directrices de la Société canadienne de cardiologie (SCC) 2010 pour le traitement antiplaquettaire en milieu extrahospitalier furent publiées en mai 2011. Avec une réévaluation planifiée en dedans de 2 ans, nous avons effectué une recherche exhaustive de la littérature couvrant tous les sujets inclus dans les lignes directrices de la SCC 2010 et conclu qu’il y avait suffisamment de nouvelles données probantes publiées qui justifiaient une mise à jour ciblée des lignes directrices pour l'utilisation des thérapies antiplaquettaires pour la prévention secondaire durant la première année après un syndrome coronarien aigu (SCA), une intervention coronarienne percutanée, ou une revascularisation chirurgicale par pontages et les interactions entre le clopidogrel et les inhibiteurs de la pompe à protons (IPP). De plus, le comité a estimé que la publication d’essais cliniques pivots évaluant l’efficacité et la sécurité d’ajouter un nouvel anticoagulant oral à la thérapie antiplaquettaire chez un patient avec SCA exigeait l’addition d’une nouvelle section de recommandations pour ces lignes directrices. Dans cette mise à jour ciblée, nous présentons des recommandations pour l'utilisation du clopidogrel, du ticagrelor et du prasugrel pour les SCA sans élévation du segment ST, d’éviter le prasugrel chez les patients avec antécédents d'accident vasculaire cérébral/ischémie cérébrale transitoire, de doses plus élevées de clopidogrel (150 mg/jour) pour les premiers 6 jours post-SCA, et l'utilisation préférentielle du prasugrel ou du ticagrelor après l’angioplastie lors d'un SCA. Pour les patients stables, nous recommandons acide acétylsalicylique/clopidogrel pour 1 an, avec un minimum d'un mois post-tuteur non médicamenté et 3 mois après tuteur médicamenté chez les patients ne pouvant tolérer la thérapie anti-plaquettaire double pour une année complète. Nous avons considéré le traitement des patients avec thrombose de tuteur, les indications pour le traitement à plus long terme, l'interruption en peri-opératoire, les indications pour changer d'agents, l'utilisation pré et post-pontages, et la sélection des patients pour thérapie concomitante avec les IPP.

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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Racial differences in P2Y12 inhibitor responsiveness in patients undergoing neuro-endovascular procedures: A cohort from the Middle East
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Data on P2Y12 inhibitors responsiveness from the middle east is scarce. We sought to investigate patient responsiveness to P2Y12 inhibitors within a cohort of major races that characterize the UAE population. The secondary objective was to assess risk factors for hyper and hypo-responsiveness in this population.
We conducted a cross-sectional study on adults who received either clopidogrel or ticagrelor treatments and had platelet responsiveness testing before undergoing neuro-endovascular interventions at our quaternary care hospital between March 2015 and April 2019.
During the study period, 249 subjects met the inclusion criteria. Overall, 17.3 % were hyper-responsive and 25.7 % were hypo-responsive to P2Y12 inhibitors. When comparing between the P2Y12 inhibitors, rates of hyper-responsiveness were significantly higher to ticagrelor when compared to clopidogrel (11 versus 6 %, p = 0.02 respectively). Contrarily, hypo-responsiveness rates were significantly higher in clopidogrel treated patients compared to their ticagrelor treated counterparts (23 versus 2 %, p < .001 respectively). Patients of Middle-Eastern origin showed a significantly higher rate of hypo-responsiveness to both clopidogrel and ticagrelor when compared to other races (41.1 % and 26.7 %, P < 0.001 respectively). Asians showed the highest rates of hyper-responsiveness for both agents. Multivariate logistic regression analysis showed that proton pump inhibitors and statin combination, (OR: 6.39, 95 %CI [1.60, 25.392]), and Middle East vs. Indian subcontinent patients (OR: 4.67, 95 %CI [1.79–12.14]) were independent predictors of hypo-responsiveness to both P2Y12 inhibitors.
This study demonstrated a high rate of hypo-responsiveness to P2Y12 inhibitors in a UAE cohort of patients undergoing neuro-endovascular procedures. In addition, therapeutic responsiveness to P2Y12 inhibitors varied markedly based on the racial background. Future larger studies are needed to evaluate genetic variations that may contribute to this rate of hypo-responsiveness in our population.
Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology 2023 Focused Update of the Guidelines for the Use of Antiplatelet Therapy
2024, Canadian Journal of Cardiology
Antiplatelet therapy (APT) is the foundation of treatment and prevention of atherothrombotic events in patients with atherosclerotic cardiovascular disease. Selecting the optimal APT strategies to reduce major adverse cardiovascular events, while balancing bleeding risk, requires ongoing review of clinical trials. Appended, the focused update of the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines for the use of APT provides recommendations on the following topics: (1) use of acetylsalicylic acid in primary prevention of atherosclerotic cardiovascular disease; (2) dual APT (DAPT) duration after percutaneous coronary intervention (PCI) in patients at high bleeding risk; (3) potent DAPT (P2Y₁₂ inhibitor) choice in patients who present with an acute coronary syndrome (ACS) and possible DAPT de-escalation strategies after PCI; (4) choice and duration of DAPT in ACS patients who are medically treated without revascularization; (5) pretreatment with DAPT (P2Y₁₂ inhibitor) before elective or nonelective coronary angiography; (6) perioperative and longer-term APT management in patients who require coronary artery bypass grafting surgery; and (7) use of APT in patients with atrial fibrillation who require oral anticoagulation after PCI or medically managed ACS. These recommendations are all on the basis of systematic reviews and meta-analyses conducted as part of the development of these guidelines, provided in the Supplementary Material.
Le traitement antiplaquettaire est la base du traitement et de la prévention des manifestations athérothrombotiques chez les patients atteints d’une maladie cardiovasculaire athéroscléreuse. Le choix du traitement antiplaquettaire approprié pour réduire les événements cardiovasculaires indésirables majeurs, tout en tenant compte du risque de saignement, demande un suivi constant des essais cliniques. En annexe, la mise à jour ciblée des lignes directrices de la Société cardiovasculaire du Canada/Association canadienne de cardiologie d’intervention pour l’utilisation du traitement antiplaquettaire formule des recommandations sur les sujets suivants : 1) l’emploi de l’acide acétylsalicylique dans la prévention primaire des maladies cardiovasculaires athéroscléreuses; 2) la durée de la bithérapie antiplaquettaire après une intervention coronarienne percutanée (ICP) chez les patients qui présentent un risque élevé de saignement; 3) le choix d’une bithérapie antiplaquettaire puissante (inhibiteur de P2Y₁₂) chez les patients qui présentent un syndrome coronarien aigu et les stratégies éventuelles de désescalade de la bithérapie antiplaquettaire après une ICP; 4) le choix et la durée de la bithérapie antiplaquettaire chez les patients atteints du syndrome coronarien aigu qui reçoivent un traitement médical sans revascularisation; 5) le prétraitement par une bithérapie antiplaquettaire (inhibiteur de P2Y₁₂) avant une coronarographie non urgente ou urgente; 6) la prise en charge par un traitement antiplaquettaire périopératoire et à long terme chez les patients qui ont besoin d’un pontage aortocoronarien; et 7) l’utilisation du traitement antiplaquettaire chez les patients qui présentent une fibrillation auriculaire et qui ont besoin d’un traitement anticoagulant par voie orale après une ICP ou qui présentent un syndrome coronarien aigu traité médicalement. Toutes les recommandations reposent sur les analyses des publications et les méta-analyses menées dans le but de formuler ces lignes directrices, fournies dans le matériel supplémentaire.
Aspirin for the Primary Prevention of Vascular Ischemic Events: An Updated Systematic Review and Meta-analysis to Support Shared Decision-Making
2023, CJC Open
Since the publication of the 2010 Canadian antiplatelet guidelines, several large randomized controlled trials (RCTs) have evaluated the role of aspirin (ASA) use in primary prevention. We evaluated the effect of ASA use, compared with no ASA, on ischemic and bleeding events in patients without known atherosclerotic cardiovascular diseases.
We updated a published systematic review and meta-analysis by searching MEDLINE, Embase, and CENTRAL for the period up to March 2023. We included RCTs that enrolled patients for primary prevention of atherosclerotic cardiovascular diseases, and compared use of ASA to no ASA. We assessed risk of bias (RoB) using the Cochrane RoB tool, and certainty of evidence using the grading recommendations, assessment, development, and evaluation (GRADE) criteria. The primary efficacy outcome was major adverse cardiovascular events (MACE) (death, myocardial infarction, or stroke). The primary safety outcomes were intracranial hemorrhage and extracranial major bleeding events. We used a random-effects model to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs).
We included 14 RCTs (n = 167,587) at overall low RoB, with a median follow-up of 5 years. Compared to no ASA, ASA use reduced the incidence of MACE (RR 0.90, 95% CI 0.86-0.94), with a higher risk of intracranial hemorrhage (RR 1.33, 95% CI 1.13-1.56) and extracranial major bleeding (RR 1.67, 95% CI 1.36-2.06). In prespecified subgroups of age, sex, and diabetes, effect estimates were consistent.
ASA use in primary prevention is associated with a consistent reduction in MACE, but at the expense of major bleeding events. Patient values and preferences should be taken into account when considering ASA use for primary prevention.
Depuis la publication, en 2010, des lignes directrices canadiennes sur les agents antiplaquettaires, plusieurs importants essais contrôlés randomisés (ECR) ont été menés pour évaluer le rôle de l’aspirine (AAS) en prévention primaire. Nous avons comparé l’effet de l’AAS à la non-utilisation de l’AAS sur les événements ischémiques et hémorragiques chez des patients présentant une maladie cardiovasculaire athéroscléreuse (MCVAS) connue.
Nous avons mis à jour une revue systématique et une méta-analyse déjà publiées en effectuant une recherche dans les bases de données MEDLINE, Embase et CENTRAL jusqu’en mars 2023. Nous avons inclus les ECR ayant porté sur la prévention primaire de la MCVAS chez les patients et comparé l’AAS et la non-utilisation de l’AAS. Nous avons évalué le risque de biais à l’aide de l’outil RoB de Cochrane, et le degré de certitude des données probantes au moyen des critères GRADE. Le principal critère d’évaluation de l’efficacité était les événements cardiovasculaires indésirables majeurs (ECIM; décès, infarctus du myocarde ou accident vasculaire cérébral). Les principaux critères d’évaluation de l’innocuité étaient les hémorragies intracrâniennes (HIC) et les saignements extracrâniens majeurs (SECM). Nous avons utilisé un modèle à effets aléatoires afin de générer les rapports de risque (RR) et les intervalles de confiance (IC) à 95 % regroupés.
Nous avons inclus 14 ECR (n = 167 587) associés à un faible risque de biais et dont le suivi médian était de 5 ans. Comparativement à la non-utilisation d’AAS, l’AAS a réduit les ECIM (RR : 0,90; IC à 95 % : 0,86-0,94), mais était associé à un risque plus élevé d’HIC (RR : 1,33; IC à 95 % : 1,13-1,56) et de SECM (RR : 1,67; IC à 95 % : 1,36-2,06). Les estimations de l’effet étaient constantes dans les sous-groupes définis au préalable selon l’âge, le sexe et le diabète.
En prévention primaire, l’AAS est associé à une réduction systématique des ECIM, mais au détriment de manifestations hémorragiques majeures. Les valeurs et les préférences du patient doivent être prises en compte lorsqu’on envisage l’AAS en prévention primaire.
Evolution of and Evidence-Practice Gaps in Antithrombotic Management of Atrial Fibrillation Patients After Percutaneous Coronary Intervention
2023, CJC Open
The management of atrial fibrillation and flutter (AF) patients undergoing percutaneous coronary intervention (PCI) has evolved rapidly in the past decade. We determine whether the publication of the 2016 Canadian Cardiovascular Society AF guidelines were associated with a shift in practice patterns.
Using Quebec provincial administrative database information for the period from 2010-2017, a retrospective cohort of patients with inpatient or outpatient coding for AF, who subsequently underwent PCI with placement of a coronary stent, was created and analyzed for the antithrombotic regimen received in the following year. Prescribing behavior was compared among 3 time periods (2010-2011, 2012-2015, 2016-2017), and use of antithrombotics was compared to guideline-predicted therapy using the χ² test. Predictors of oral anticoagulation (OAC) prescription were identified using adjusted logistic regression.
A total of 3740 AF patients undergoing PCI were included. The proportion of OAC prescription increased over time (2010-2011 = 51.4%; 2012-2015 = 54.3%; 2016-2017 = 56.6%; P = 0.13), with a significant increase in direct OAC prescription (P < 0.01). A substantial treatment gap in OAC prescription persisted after publication of the 2016 guidelines (56.6% observed vs 89.7% predicted; P < 0.01). Previous stroke, CHADS₂ score, Charlson Comorbidity Index ≥ 4, and prior use of direct OAC or warfarin were predictors of being exposed to OAC claims; previous major bleeding, and low-dose acetylsalicylic acid or P2Y12 inhibitor use were predictors of not being exposed to OACs.
Expert guidance contributed to an increase in OAC prescription following PCI, but up to 2017, substantial further changes in practice patterns would have been required to achieve the recommended rates of OAC prescription.
La prise en charge des patients qui sont atteints de fibrillation auriculaire (FA) ou de flutter auriculaire et qui subissent une intervention coronarienne percutanée (ICP) a évolué rapidement au cours de la dernière décennie. Nous avons voulu déterminer si la publication des lignes directrices sur la fibrillation auriculaire de la Société canadienne de cardiologie en 2016 s’était traduite par un changement de pratiques.
À partir de renseignements recueillis dans la base de données administratives du Québec en ciblant la période allant de 2010 à 2017, nous avons créé une cohorte rétrospective de patients qui, selon le code diagnostique, avaient été hospitalisés ou reçus en consultation externe pour cause de FA ou de flutter auriculaire et qui avaient par la suite subi une ICP avec mise en place d'une endoprothèse coronaire. La cohorte a été l’objet d’une analyse visant à caractériser le traitement antithrombotique administré au cours de l’année suivant l’opération, et le comportement des prescripteurs a été comparé sur trois périodes (2010-2011, 2012-2015, 2016-2017). En outre, le recours aux antithrombotiques a été comparé au traitement prévu suivant les lignes directrices au moyen du test χ². Les facteurs prédictifs de prescription d’anticoagulants oraux (ACO) ont été cernés par régression logistique corrigée.
Au total, 3 740 patients atteints de FA ou de flutter auriculaire et ayant subi une ICP ont été inclus dans la cohorte. La proportion d’ordonnances d’ACO a augmenté au fil du temps (2010-2011 = 51,4 %, 2012-2015 = 54,3 %, 2016-2017 = 56,6 %; P = 0,13), et la prescription d’ACO directs a connu une augmentation significative (P < 0,01). Un écart important sur le plan thérapeutique en matière de prescription d’ACO a persisté après la publication des lignes directrices en 2016 (proportion observée de 56,6 % vs proportion prévue de 89,7 %; P < 0,01). Les antécédents d’AVC, le score CHADS₂, un indice de comorbidité de Charlson ≥ 4 et les antécédents de traitement par des ACO directs ou la warfarine étaient des facteurs prédictifs d’exposition aux ACO; les antécédents de saignement majeur et la prise à faible dose d’acide acétylsalicylique ou d’un inhibiteur de P2Y12 étaient des facteurs prédictifs de non-exposition aux ACO.
Les avis des spécialistes ont contribué à une augmentation de la prescription d’ACO après une ICP. Toutefois, jusqu’en 2017, d’autres changements de pratique substantiels auraient été nécessaires pour atteindre les taux recommandés d’utilisation des ACO.
Cinnamon and Aspirin for Mild Ischemic Stroke or Transient Ischemic Attack: A Pilot Trial
2022, Clinical Therapeutics
Cinnamon can reduce levels of blood lipids, blood glucose, and inflammation, which are risk factors for ischemic stroke and transient ischemic attack (TIA).The goal of this study was to observe the safety and efficacy of aspirin combined with cinnamon in the treatment of patients with mild stroke or TIA.
This pilot study included patients with mild stroke or TIA treated at Guangdong Provincial People's Hospital–Nanhai Hospital between January 2014 and December 2016. The primary end point was recurrent stroke (within 90 days after the first attack; intention-to-treat analysis). The secondary end points included biochemical indices, carotid color Doppler ultrasound, safety indices, and adverse reactions.
A total of 122 patients were included, including 62 in the aspirin-cinnamon group (41 men and 21 women; mean age, 62.0 [3.5] years) and 60 in the aspirin-placebo group (40 men and 20 women; mean age, 63.0 [3.2] years). The number of participants with recurrent stroke was two (3.2%) and nine (15.0%) in the aspirin-cinnamon group and the aspirin-placebo group, respectively (P = 0.002). Compared with aspirin-cinnamon, aspirin-placebo rates of unstable plaque and severe vascular stenosis were higher, whereas the rate of mild vascular stenosis with aspirin-cinnamon was higher than with aspirin-placebo (P < 0.05). One case of mild to moderate upper gastrointestinal bleeding in each group was observed.
Among patients with TIA or mild ischemic stroke, the combination of cinnamon and aspirin could be superior to aspirin alone for reducing the risk of 90-day recurrent stroke.
Challenges of long-term dual antiplatelet therapy use following acute coronary syndromes
2022, American Heart Journal
An acute coronary syndrome (ACS) event is associated with a high risk of recurrent ACS, stroke, and death. To ameliorate the risk of subsequent events, current guidelines for ST-segment elevation myocardial infarction and non–ST-segment elevation ACS recommend long-term management strategies for secondary prevention including risk factor modification and anti-ischemic and antiplatelet therapies. Dual antiplatelet therapy (DAPT), comprising aspirin plus a P2Y₁₂ inhibitor, is a critical component of secondary prevention therapy following ACS. However, despite the importance of DAPT for secondary prevention after ACS, questions remain over the optimal duration of therapy. Clinical evidence is emerging that maintenance DAPT >12 months lowers the risk of recurrent ACS events; however, this benefit must be considered against any potential risks of prolonged DAPT such as bleeding. Several tools for bleeding risk assessment have shown promise; however, their limited accuracy and discriminative power necessitates further development. Assessment of patient ischemic risk should consider the complexity of the percutaneous coronary intervention (PCI) procedure, anatomic burden of coronary artery disease, and additional underlying risk factors. Consequently, identifying patients in whom the risk:benefit ratio favors prolonged DAPT may prove invaluable for clinicians in deciding which patients should continue or stop taking DAPT at 12 months after PCI, or consider P2Y₁₂ inhibitor monotherapy as an option. This article reviews the most recent information about the risks and benefits of DAPT continued for >12 months after ACS and provides critical guidance to assist physicians in identifying patients most likely to benefit from a secondary prevention strategy with DAPT.

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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.

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Society GuidelinesFocused 2012 Update of the Canadian Cardiovascular Society Guidelines for the Use of Antiplatelet Therapy

Abstract

Résumé

Section snippets

Optimal acetylsalicylic acid dose after ACS

Optimal duration of dual antiplatelet therapy after stent implantation

What Is the Optimal Antiplatelet Therapy Regimen After CABG?

Should Novel Oral Anticoagulants Be Used With Antiplatelet Agents for Secondary Prevention After ACS?

Should PPIs Be Used in Patients Taking DAPT That Includes Clopidogrel?

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Circualtion

Society Guidelines
Focused 2012 Update of the Canadian Cardiovascular Society Guidelines for the Use of Antiplatelet Therapy