Antiplatelets for arterial clots and anticoagulants for venous clots

It can be tricky to know when to recommend an antiplatelet, an anticoagulant, or both... These are some important questions to know the difference between antiplatelet and anticoagulant, and when to use each other...

          What's the difference between antiplatelets and anticoagulants? Generally think of antiplatelets like aspirin, clopidogrel (Plavix), ticagrelor (Brilique) for clots in the arteries due to platelet aggregation. And typically think of anticoagulants like warfarin (Marevan) or direct oral anticoagulants (DOACs), such as apixaban (Eliquis) for clots in the veins or atria of the heart due to fibrin meshes of red blood cells.

When are antiplatelets first-line? Recommend an antiplatelet to prevent an ischemic stroke or heart attack. For example, suggest low-dose aspirin, clopidogrel, or dipyridamole ER/aspirin to prevent recurrent ischemic stroke or transient ischemic attack (TIA). Or recommend aspirin 81 mg/day alone in a patient with stable heart disease, or in combination with clopidogrel after a recent coronary stent. For further information, see note on "Using TWO antiplatelets short-term after a minor stroke or transient ischemic attack".

When are anticoagulants first-line? Recommend an anticoagulant for atrial fibrillation, a prosthetic heart valve, or to treat venous thromboembolism (VTE). Expect more atrial fibrillation or VTE patients to be on a DOAC instead of warfarin. DOACs work at least as well as warfarin, have a lower risk of major bleeding, and can be easier to use. Advise sticking with warfarin for most patients with a prosthetic valve. There's not much evidence yet about using DOACs in this case. For further information, see note on "Diagnosis and treatment of atrial fibrillation".

When should antiplatelets and anticoagulants be combined?  This most often comes up when patients have multiple cardiovascular conditions such as a patient with atrial fibrillation who needs a coronary stent. Many of these patients end up on "triple antithrombotic therapy" generally warfarin, clopidogrel, and aspirin for 3 to 6 months. Check with the physician if you see longer durations of triple antithrombotic therapy since bleeding risk is high. For further information, see note on "Is the combination of aspirin, clopidogrel, and warfarin appropriate and effective or inappropriate and too dangerous?".

REFERENCES

• Levine, G., Patrick, and others. ACC/AHA FOCUSED UPDATE 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. [online] Available at: https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Tools%20and%20Practice%20Support/Quality%20Programs/Anticoag-10-14/DAPT/1%20Levine%202016%20DAPT%20Guidelines.pdf?la=en

  Kernan, W.N., Ovbiagele, B., and others. American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease (2014). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, [online] 45(7), pp.2160–236. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24788967

  January, C.T., Wann, L.S., and others. 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation. Journal of the American College of Cardiology, 64(21), pp.e1–e76. Available at: https://pubmed.ncbi.nlm.nih.gov/24685669

  Kearon, C., Akl, E.A., Ornelas, and others (2016). Antithrombotic Therapy for VTE Disease. Chest, [online] 149(2), pp.315–352. Available at: http://www.sciencedirect.com/science/article/pii/S0012369215003359

  Nishimura, R.A., Otto, C.M., and others. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 135(25). Available at: https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000503