Antiplatelets for arterial clots and anticoagulants for venous clots

Generally think of antiplatelets like aspirin, clopidogrel (Plavix), ticagrelor (Brilique) for clots in the arteries due to platelet aggregation....

Overview

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...

Clinical practice

What Are Antiplatelets and Anticoagulants?

Antiplatelets: Medications like aspirin, clopidogrel (Plavix), and ticagrelor (Brilique) that prevent blood clots from forming in arteries. They work by inhibiting platelet aggregation.
Anticoagulants: Medications such as warfarin (Marevan) and direct oral anticoagulants (DOACs) like apixaban (Eliquis) that prevent blood clots in veins or the atria of the heart. They work by disrupting the clotting cascade, primarily affecting fibrin formation.

When Are Antiplatelets First-Line?

Ischemic Stroke or Heart Attack Prevention: Use antiplatelets to prevent recurrent ischemic stroke or transient ischemic attack (TIA).
- Examples: Low-dose aspirin, clopidogrel, or dipyridamole ER/aspirin.
- For Stable Heart Disease: Aspirin 81 mg/day alone is often recommended.
- After Coronary Stent: Combination of aspirin and clopidogrel may be advised.
- Short-Term Use: For minor stroke or TIA, refer to "Using TWO antiplatelets short-term after a minor stroke or transient ischemic attack."

When Are Anticoagulants First-Line?

Atrial Fibrillation: Anticoagulants are preferred to prevent stroke and systemic embolism.
- DOACs: Apixaban (Eliquis), rivaroxaban (Xarelto), or dabigatran (Pradaxa) are often recommended over warfarin due to ease of use and lower bleeding risk.
- Prosthetic Heart Valve: Warfarin remains the standard choice for most patients.
- Venous Thromboembolism (VTE): Anticoagulants are used for treatment and prevention.
- Further Reading: See "Diagnosis and treatment of atrial fibrillation" for detailed guidance.

When Should Antiplatelets and Anticoagulants Be Combined?

Multiple Cardiovascular Conditions: Combination therapy may be required for patients with conditions such as atrial fibrillation who also need a coronary stent.
- Triple Antithrombotic Therapy: Often includes warfarin, clopidogrel, and aspirin for 3 to 6 months.
- Risk of Bleeding: Monitor closely due to high bleeding risk; consult a physician for extended durations.
- Further Information: Refer to "Is the combination of aspirin, clopidogrel, and warfarin appropriate and effective or inappropriate and too dangerous?" for more on managing combination therapy.

References

Glenn N. Levine, Eric R. Bates, John A. Bittl, et al. 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://doi.org/10.1016/j.jacc.2016.03.513
Kernan WN, Ovbiagele B, Black HR, et al. 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. 2014;45(7):2160-2236.
January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):e1-e76.
Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016;149(2):315-352.
Nishimura, R.A., Otto, C.M., et al. 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).