A Case Based Discussion

1. Case Based Management on DAPT, VKA, NOAC
Presenter: Dr. Azim Anwar
Chairperson: Dr. Fakhrul Islam Khaled
Asso. Professor, Dept of Cardiology, BSMMU

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…….

5. Echocardiography:
Apical Hypokinesia. EF 40%
LV thrombus.

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

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

13. Should we continue Prasugrel as part
of DAPT for this NSTEMI ?

14. So What P2Y12 if Prasugrel not
indicated ?
Ticagrelor

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 !

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

21. Can we Stop DAPT and only cont. OAC
?

22. Duration of OAC ?
Between 1-6 months.
High Ischemic risk: 6 months
High Bleeding risk: 1 month

23. OAC in Normal dose or less ?
Lowest approved dose.
Ticagrelor or Prasurel contraindicated
in triple therapy

24. Case 4
• Mr. M, 35 Years
• Ischemic Stroke 6 months back..
• Was on DAPT (E75+C75)
• Suddenly developed melena
• Endoscopy: Bleeding duodenal ulcer
• Hb – 6 gm/dL (Previously 10 g/dl)
•

25. • Should we stop DAPT ?

26. Dual Therapy Triple Therapy
Trivial Bleeding
(Epistaxis, Bruish, Echymosis)
Cont DAPT Skip single dose OAC
Mild Bleeding
(Nonresolving Epistaxis,
Upper or lower GI bleed, GU
bleed)
Cont DAPT.
Clopidogrel instead of
Ticagrelor or Prasugrel.
Continue Clopidogrel + OAC
Moderate Bleeding
(>3 gm/dl loss)
Hemodynamically stable
Cont SAPT with Clopidogrel Stop OAC and DAPT.
Start after 1 week with 2-2.5
INR with Clopid + OAC
Severe Bleeding
(>5 gm/dl loss)
Hemodynamically stable
Cont SAPT with
Clopidogrel.
If bleeding persists, Stop
SAPT.
Start when bleeding ceased
in shortest duration, with
Clopidogrel
Stop OAC and DAPT.
Start after 1 week with 2-2.5
INR with Clopid + OAC
Life Threatening Bleeding Stop DAPT.
Start when bleeding ceased
Stop & reverse OAC