Anticoagulation and Antiplatelet Therapy

Indications and Recommendations

• The American College of Cardiology recommends anticoagulants for atrial fibrillation to prevent cardioembolic stroke, venous thromboembolism, and mechanical heart valves 1, 2, 3
• The American College of Cardiology recommends antiplatelets for atherosclerotic cardiovascular disease, including coronary artery disease, noncardioembolic stroke, peripheral artery disease, post-percutaneous coronary intervention, and acute coronary syndromes 1, 5, 6
• For noncardioembolic stroke, antiplatelet therapy is the standard treatment, with oral anticoagulation not preferred (Grade 1B evidence) 4
• For stroke with atrial fibrillation, oral anticoagulation is required, with DOACs preferred over warfarin (Grade 1A evidence) 4

Combination Therapy

• The American College of Cardiology recommends dual antithrombotic therapy (anticoagulant + P2Y12 inhibitor) over triple therapy for patients requiring both anticoagulation and antiplatelet therapy 1, 7, 8
• Clopidogrel is preferred over more potent P2Y12 inhibitors when combination therapy is needed 1, 7, 8
• DOACs are preferred over vitamin K antagonists (warfarin) when combination antithrombotic therapy is required 1, 7, 8

Duration of Therapy

• The American College of Cardiology recommends continuing antiplatelet therapy for 1 year post-PCI in patients requiring indefinite anticoagulation 1, 8
• After 12 months post-PCI, anticoagulant alone can be used long-term 5, 6

Special Considerations

• The American College of Cardiology warns against confusing prophylactic-dose anticoagulation with therapeutic anticoagulation 4
• Cerebral amyloid angiopathy carries a high risk of recurrent intracranial hemorrhage and generally precludes anticoagulation use 4