Case 1

A 68 year old man is sent to the ER by his GP with new onset asymptomatic atrial fibrillation.  He had an angiogram 10 years ago, which demonstrated mild coronary disease, but has not had stents, and is asymptomatic.  He has no other medical problems.

His only medications are ASA and rosuvastatin.

You put him on metoprolol 25mg bid to rate control his AF.  What would you recommend regarding his stable CAD and stroke prevention:

A. ASA + rivaroxaban 20mg
B. Rivaroxaban 20mg daily (d/c ASA)
C. ASA + rivaroxaban 2.5 daily (low dose)
D. ASA only (continue unchanged)

Case 1

A 68 year old man is sent to the ER by his GP with new onset asymptomatic atrial fibrillation.  He had an angiogram 10 years ago, which demonstrated mild coronary disease, but has not had stents, and is asymptomatic.  He has no other medical problems.

His only medications are ASA and rosuvastatin.

You put him on metoprolol 25mg bid to rate control his AF.  What would you recommend regarding his stable CAD and stroke prevention:

A. ASA + rivaroxaban 20mg
B. Rivaroxaban 20mg daily (d/c ASA)
C. ASA + rivaroxaban 2.5 daily (low dose)
D. ASA only (continue unchanged)

Case 2

An 85yo woman has a history of NSTEMI 1 years ago.  He received a DES to the LAD, and has no other coronary lesions.  His current medications are: ASA 81mg daily, Ticagrelor 90mg bid, Ramipril 10mg daily, Rosuvastatin 10mg daily.  
His past medical history includes dyslipidemia, diet controlled diabetes, and CKD BL creat 210 (GFR 34 mL/min)

What is your recommendation regarding his antiplatelet therapy?

A. ASA monotherapy (Stop ticagrelor)
B. ASA + clopidogrel 75mg daily
C. ASA + ticagrelor 90mg bid
D. ASA + ticagrelor 60mg bid
E. Hematology consult

Case 2

An 85yo woman has a history of NSTEMI 1 years ago.  He received a DES to the LAD, and has no other coronary lesions.  His current medications are: ASA 81mg daily, Ticagrelor 90mg bid, Ramipril 10mg daily, Rosuvastatin 10mg daily.  
His past medical history includes dyslipidemia, diet controlled diabetes, and CKD BL creat 210 (GFR 34 mL/min)

What is your recommendation regarding his antiplatelet therapy?

A. ASA monotherapy (Stop ticagrelor)
B. ASA + clopidogrel 75mg daily
C. ASA + ticagrelor 90mg bid
D. ASA + ticagrelor 60mg bid
E. Hematology consult

Case 3

A 67 year old man presents to ER with rectal bleeding.  Colonoscopy demonstrates ascending colonic lesion characteristic of colon cancer.  A CT of the abdomen demonstrates a solidary metastatic lesion in the left lobe of the liver.  He also has a history of NSTEMI 2 weeks ago, and received a drug-eluting stent to his mid LAD.  
The surgeon calls you and asks for your advice on the management of patient’s antiplatelet therapy.  He wants to operate as soon as possible to improve outcomes, but bleeding risk is too high to operate on DAPT. 

Patient is currently on ASA 81mg,  Ticagrelor 90mg bid, bisoprolol 2.5mg daily, rosuvastatin 40mg daily

What is your recommendation?
A. ASA? Ticagrelor?
B. Delay surgery? How long?

Case 3

A 67 year old man presents to ER with rectal bleeding.  Colonoscopy demonstrates ascending colonic lesion characteristic of colon cancer.  A CT of the abdomen demonstrates a solidary metastatic lesion in the left lobe of the liver.  He also has a history of NSTEMI 2 weeks ago, and received a drug-eluting stent to his mid LAD.  
The surgeon calls you and asks for your advice on the management of patient’s antiplatelet therapy.  He wants to operate as soon as possible to improve outcomes, but bleeding risk is too high to operate on DAPT. 

Patient is currently on ASA 81mg,  Ticagrelor 90mg bid, bisoprolol 2.5mg daily, rosuvastatin 40mg daily

What is your recommendation?

Hold Ticagrelor 4 weeks after the stent, operate 5 days after (delay surgery until that time). Continue ASA.

Case 4

A 56 year old man with an MI tells you he has no drug plan, and wants to be on clopidogrel instead if prasugrel.

Which is correct with regards to switching between clopidogrel and ticagrelor?

A. Stop prasugrel, reload 600mg clopidogrel at time of next prasugrel dose

B. Stop prasugrel, reload 600mg clopidogrel now

C. Stop prasugrel, resume clopidogrel 75mg at the time of next prasugrel dose

D. Stop prasugrel, resume clopidogrel 75mg daily, first dose now.

The loading dose of 600 mg conveys a short-term (48 hours) pharmacodynamic advantage after the switch to clopidogrel that might be relevant in the early post-ACS/PCI period. In patients who are stable, a loading dose of 300 mg or switching directly to 75 mg daily with no loading dose are also reasonable options, especially for patients believed to be at high risk for bleeding.

The optimal time for the initiation of clopidogrel has not been extensively studied. In OPTI-CROSS, the switch was made at the next scheduled ticagrelor dose; extending to the following morning (ie, 24 hours after the last ticagrelor dose) might also be reasonable on the basis of pharmacodynamics data from the Response to Ticagrelor in Clopidogrel Nonresponders and Responders and Effect of Switching Therapies (RESPOND) study

Case 4

A 56 year old man with an MI tells you he has no drug plan, and wants to be on prasugrel instead if ticagrelor.

Which is correct with regards to switching between clopidogrel and ticagrelor?

A. Stop prasugrel, reload 600mg clopidogrel at time of next prasugrel dose

B. Stop prasugrel, reload 600mg clopidogrel now

C. Stop prasugrel, resume clopidogrel 75mg at the time of next prasugrel dose

D. Stop prasugrel, resume clopidogrel 75mg daily, first dose now.

Case 5

A 57 year old man presents on Friday night with an NSTEMI.  He has a history of hypertension and atrial fibrillation.  He has never had any issues with bleeding.
His medications include rivaroxaban 20mg daily and ramipril 10mg daily.

You book him for an angiogram on Monday (in 2 days) and anticipate a stent will be placed.

How would you manage his antiplatelet therapy?

BE SPECIFIC!!   Specify:
A. What to put him on NOW
B.  What to put him on AFTER his stent.

Triple Tx:

• Warfarin 2-2.5
• Riva 2.5 BID

ASA 1d - 6mo

Dual Tx:

• Warfarin
• Riva 15
• Dabi 110/150

NOAC preferred

Case 5

Before Cath:

Clopidogrel + OAC until his cath

Day of Cath:

ASA 160mg x1 PO

After Cath:

Choose your own adventure