Chronic anticoagulation after acute coronary syndromes
- Gregory YH Lip, MD, FRCPE, FESC, FACC
Gregory YH Lip, MD, FRCPE, FESC, FACC
- Professor of Cardiovascular Medicine
- The University of Birmingham, UK
- Section Editors
- Freek Verheugt, MD, FACC, FESC
Freek Verheugt, MD, FACC, FESC
- Section Editor — Coronary Heart Disease
- Onze Lieve Vrouwe Gasthuis, Netherlands
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
In some patients with an acute coronary syndrome (ACS) (see "Criteria for the diagnosis of acute myocardial infarction", section on 'Acute coronary syndrome'), chronic oral anticoagulation is required to lower the risk of systemic (arterial) thromboembolism, such as those with atrial fibrillation, left ventricular systolic dysfunction or thrombus, or prosthetic heart valves. (See "Atrial fibrillation: Anticoagulant therapy to prevent embolization" and "Antithrombotic therapy in patients with heart failure" and "Left ventricular thrombus after acute myocardial infarction", section on 'Prevention of formation' and "Antithrombotic therapy for prosthetic heart valves: Indications".)
ACS patients are routinely treated with aspirin and a P2Y12 receptor blocker (eg, clopidogrel, prasugrel, or ticagrelor) to decrease the risk of recurrent events (See "Antiplatelet agents in acute non-ST elevation acute coronary syndromes", section on 'Summary and recommendations' and "Antiplatelet agents in acute ST elevation myocardial infarction", section on 'Summary and recommendations'.) Thus, those who also require oral anticoagulation are discharged on triple oral anticoagulant therapy (TOAT). (See "Triple antithrombotic therapy in patients with cardiovascular disease".)
The issue of whether chronic anticoagulant therapy reduces the risk of recurrent cardiovascular events, such as myocardial infarction (MI) or cardiac death, after ACS has been evaluated in clinical trials. The rationale for a potential role of chronic anticoagulant therapy in this setting is based on the following two pieces of information:
●The high rates of recurrent ischemic events after ACS due, at least in part, to a persistent thrombotic risk within the coronary circulation. This thrombotic risk stems from heightened platelet reactivity, an increase in activity of some or all of the elements of the coagulation cascade, or both. (See "Overview of hemostasis".)
●The proven efficacy of long-term antithrombotic therapy with dual antiplatelet therapy in reducing recurrent ischemic events in most patients with an ACS. (See "Overview of the acute management of unstable angina and non-ST elevation myocardial infarction" and "Overview of the acute management of ST elevation myocardial infarction".)
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- BIOLOGIC PLAUSIBILITY
- PATIENTS WITHOUT OTHER INDICATIONS FOR CHRONIC ANTICOAGULATION
- - Meta-analyses
- - Randomized trials
- - Patients taking dual antiplatelet therapy
- - Patients not taking a platelet P2Y12 receptor blocker
- PATIENTS WITH INDICATIONS FOR CHRONIC ANTICOAGULATION
- Stented patients
- Non-stented patients
- RECOMMENDATIONS OF OTHERS
- BLEEDING RISK
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS