Geno J. Merli, MD; Howard H. Weitz, MD
Disclosures: Geno J. Merli, MD, reports the following: Research grants/contracts: Bristol-Myers Squibb, Bayer, sanofi-aventis; Consultancies: Bristol-Myers Squibb, Bayer, sanofi-aventis. Howard H. Weitz, MD, reports that he has no financial relationships or interests to disclose.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
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Jonathan Hager, MD
Primary Care Internal Medicine, Rochester NY
March 26, 2015
Do you put all of these triple therapy patients on PPI for the duration of triple therapy?If so, you might want to mention that in the video. If not, why not?It would be nice to have actual absolute percent risks of stroke broken down by CHads-Vasc score rather than just the CHads-Vasc score in this setting. For example,I believe the SPAF data showed that without anticoagulation the annual risk of stroke is about 6% with coumadin and drops to about 2%. With ASA alone, its about 3%- for 12 months. So a patient with one month of dual antiplatelet rx but no coumadin might only face 3/12% risk of stroke in that one month off coumadin, right? This patient is probably higher risk than the SPAF patients. I wonder what his percent risk of stroke is for one month only on dual platelet rx? With 22% risk of serious bleeding (7% per month), knowing his 1 month risk of stroke, might change that dynamic.
The Consult Guys (Geno and Howard)
May 1, 2015
Anticoagulation? Antiplatelet? What is the score?
Regarding proton pump inhibitor (PPI) use in the setting of triple antithrombotic therapy (vitamin K antagonist, aspirin, P2Y12 receptor inhibitor) the only evidence to guide us is level C (Consensus). We follow the recommendations of the 2014 American Heart Association / American College of Cardiology Non ST Elevation Acute Coronary Syndrome Guideline which recommends PPI use in patients on triple antithrombotic therapy and a known history of gastrointestinal bleeding (Class I recommendation). For the patient without a history of gastrointestinal bleeding PPI use is suggested but the recommendation is weaker (Class IIa recommendation).The CHADS2 and the CHA2DS2-VASc scores are based on an annual rate of stroke or embolism. Since timing of stroke risk is not linear, the risk of embolic phenomena cannot be calculated on a daily, weekly or monthly fractional basis.( Ref Amsterdam EA, Wenger NK, Brindis RC, et al. 2014 AHA/ACC Guideline for the management of patients with non-ST Elevation acute coronary syndromes: A report from the American College of Cardiology / American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014: 64(24) e139-228
Merli GJ, Weitz HH. The Consult Guys - Anticoagulation? Antiplatelet? What's the Score?. Ann Intern Med. ;162:CG1. doi: 10.7326/G15-3003
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Published: Ann Intern Med. 2015;162(6):CG1.
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