A Critique of the Proposed National Education Policy Reform
14. DAPT, VKA, OAC- Case Based Approach
1. Case Based Management on DAPT, VKA, NOAC
Presenter: Dr. Azim Anwar
Chairperson: Dr. Fakhrul Islam Khaled
Asso. Professor, Dept of Cardiology, BSMMU
2.
3. Case : 01
• Mr. A, 60 YeARS
• Presented with
ASTEMI Ant ( 5 day after onset of chest pain)
No active complains
Hemodynamically Stable
Treated with DAPT, LMWH, Nitrates…….
6. • Patient is on Ecospirin, Clopidogrel.
• LV thrombus on Echocardiography.
• How will we manage the LV thrombus ?
• Should we add anticoagulant ?
• Choice of Anticoagulation- VKA / NOAC ?
• Duration of triple therapy ?
7. P
Prophylactic anticoagulation may be given in STEMI Ant and
apical akinesia or dyskinesia (INR 2-2.5)
Conflicting evidence of VKA vs NOAC in head to head. VKA
(INR 2-3) is recommended. NOAC if VKA not tolerated.
Imaging after 3 months of starting OAC.
If resolved, discont OAC and cont DAPT, repeat imaging after 3
months
If not resolved, cont OAC for another 3 months and imaging..
8. Case 02
• Mr. C, 42 Years
• NSTEMI ( Chest Pain– 2days, hsTrop I- 25000)
• HTN
• CAG in 2018 TVD PCI to RCA
• No followup after that, since April, 2018.
• Since 2018, DAPT (E 75 +P 10 + A 20)
9. Was starting Prasugrel instead of ticagrelor after
NST ACS PCI was appropriate ?
1. NST ACS patient, naïve to P2Y12 inhibitor,
undergoing CAG +_ PCI
2. STEMI, initially managed conservatively, but
now undergoing PCI
3. STEMI undergoing immediate PCI
4. With aspirin in stable CAD if Syntax score high
or stent thrombosis.
Contraindication:
1. High risk of life threatening bleeding.
2. NST ACS with unknown coronary anatomy
3. Medically managed ACS
10.
11.
12. Rationale what should be the duration
of DAPT ?
Prolong DAPT (6-30 Months)
In patients of ACS ---
1. Well tolerated DAPT without bleeding complications.
2. At low bleeding risk
3. High thrombotic risk
14. So What P2Y12 if Prasugrel not
indicated ?
Ticagrelor
15.
16. Case 3
• Mr. Z, 55 Years
• NSTEMI (Trop I: 8000—4000-- 2000)
• Ecospirin, Clopidogrel, Atorvastatin, LMWH
• LMWH was stopped on 7th day
• Complained pain in left forearm, 4 days after
stopping LMWH !
17.
18. • Patient is on DAPT and statin.
• What we can add for DVT ?
19. • First episode of DVT (acut DVT) in upper limb,
provoked or unprovoked,
NOAC (Apixaban,Rivaroxaban, Edoxaban,
Dabigatran)
VKA ( INR 2-3) [LMWH untill INR >2]
3-6 months initially…….
Recanalization
Bleeding Risk