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.
Terms of Use
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Jonathan Hager, MD
Primary Care Internal Medicine, Rochester NY
March 26, 2015
bleeding risks
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)
Consult Guys
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. 2015;162:CG1. doi: https://doi.org/10.7326/G15-3003
Download citation file:
© 2019
Published: Ann Intern Med. 2015;162(6):CG1.
DOI: 10.7326/G15-3003
Results provided by: