The Use of Antiplatelet Therapy in the Outpatient Setting: Canadian Cardiovascular Society Guidelines

Postdischarge management of acute coronary syndrome. After an acute coronary syndrome, the outpatient antiplatelet therapy recommendations after ST-elevation myocardial infarction (STEMI) or non–ST-segment elevation acute coronary syndrome (NSTEACS) in medically managed or after percutaneous intervention. In general, the ADP P2Y₁₂ receptor antagonist added to ASA in the acute setting should be maintained for the duration of therapy (Class I, Level C). ADP, adenosine diphosphate; ASA, acetylsalicylate acid; CABG, coronary artery bypass graft. *Currently under review by Health Canada. All recommendations concerning ticagrelor are conditional on approval by Health Canada.

Postdischarge management of ST-elevation myocardial infarction (STEMI). The outpatient management after a STEMI is outlined for patients medically managed or after percutaneous intervention. In general, the ADP P2Y₁₂ receptor antagonist added to ASA in the acute setting should be maintained for the duration of therapy (Class I, Level C). ADP, adenosine diphosphate; ASA, acetylsalicylate acid; CABG, coronary artery bypass graft. *Currently under review by Health Canada. All recommendations concerning ticagrelor are conditional on approval by Health Canada.

Postdischarge management of non-ST-segment elevation acute coronary syndrome (NSTEACS). The outpatient management after a NSTEACS is outlined for patients medically managed or after percutaneous intervention. In general, the ADP P2Y₁₂ receptor antagonist added to ASA in the acute setting should be maintained for the duration of therapy (Class I, Level C). ADP, adenosine diphosphate; ASA, acetylsalicylate acid; CABG, coronary artery bypass graft. *Currently under review by Health Canada. All recommendations concerning ticagrelor are conditional on approval by Health Canada.

Postdischarge management of patients undergoing percutaneous coronary intervention (PCI). The outpatient management after a PCI is outlined for patients receiving a bare-metal stent or drug-eluting stent. ASA, acetylsalicylate acid; CABG, coronary artery bypass graft. *Currently under review by Health Canada. All recommendations concerning ticagrelor are conditional on approval by Health Canada.

Management of stable coronary artery disease. The outpatient management of patients with stable coronary artery disease or more than one year after an acute coronary syndrome may consider dual-antiplatelet therapy if high risk of thrombosis and low risk of bleeding. ACS, acute coronary syndrome: ASA, acetylsalicylate acid.

Management of post-coronary artery bypass graft. The outpatient management of patients after coronary artery bypass graft is outlined in this figure and may include dual-antiplatelet therapy when a recently stented vessel is not adequately bypassed. ASA, acetylsalicylate acid; CABG, coronary artery bypass graft; PCI, percutaneous coronary intervention.

Management of transient ischemic attack (TIA) and ischemic stroke. The outpatient management of TIA or ischemic stroke of noncardiac origin can include dual-antiplatelet therapy for the first month. ASA, acetylsalicylate acid; ER, extended-release; TIA, transient ischemic attack.

Management of peripheral arterial disease (PAD). The outpatient management of patients with symptomatic or asymptomatic PAD is outlined. ASA, acetylsalicylate acid; CAD, coronary artery disease. *Asymptomatic PAD is defined by ankle-brachial index < 0.9 in the absence of claudication or other manifestations of obstructive vascular disease in the extremities. ^†For patients allergic or intolerant to ASA, use of clopidogrel is suggested (Class IIa, Level B). ^‡For patients with PAD with an indication for oral anticoagulation such as atrial fibrillation, venous thromboembolism, heart failure, or mechanical valves, antiplatelet therapy should not be added to oral anticoagulation (Class III, Level A).

Management of post peripheral artery surgery. The outpatient management of patients after peripheral artery surgery or percutaneous revascularization or presenting an abdominal aortic aneurysm (AAA). ASA, acetylsalicylate acid; PAD, peripheral arterial disease. *For patients allergic or intolerant to ASA, use of clopidogrel is suggested (Class IIa, Level B).

Primary prevention in patients without evidence of manifest vascular disease. For the purpose of this guideline, primary prevention is defined as antiplatelet strategies, administered to individuals free of any evidence of manifest atherosclerotic disease in any vascular bed, to prevent clinical vascular events or manifestations thereof. These include, but are not limited to, syndromes of angina pectoris, MI, ischemic stroke, TIA, intermittent claudication, and critical limb ischemia. ASA, acetylsalicylate acid; TIA, transient ischemic attack.

Management of patients with diabetes. The outpatient management for primary and secondary prevention of vascular ischemic events in patients with diabetes. ASA, acetylsalicylate acid. *For patients allergic or intolerant to ASA, use of clopidogrel 75 mg OD is suggested (Class IIa, Level B).

Management of heart failure. The outpatient management of patient with ischemic or nonischemic heart failure. CAD, coronary artery disease.

Management of chronic kidney disease. Antiplatelet therapy for primary or secondary prevention of ischemic vascular events in patients with chronic renal disease. ASA, acetylsalicylate acid; CKD, chronic renal disease; ESRD, end-stage renal disease. *For patients allergic or intolerant to ASA, use of clopidogrel 75 mg OD is suggested (Class IIa, Level B).

Management in pregnancy and lactation. Antiplatelet therapy during pregnancy and lactation is recommended if maternal benefits clearly outweigh potential fetal/infant risks. ASA, acetylsalicylate acid. *Use of antiplatelet agents other than low-dose ASA for cardio- or cerebrovascular indications during pregnancy and lactation should only be considered if maternal benefits clearly outweigh potential fetal/infant risks (Class IIb, Level C).

Perioperative management of patients taking ASA. The perioperative antiplatelet management will vary depending on the risk of bleeding related to the diagnostic or surgical procedure and the risk of cardiovascular ischemic event. ASA, acetylsalicylate acid; CABG, coronary artery bypass graft.

Perioperative management of patients taking ASA and clopidogrel. The perioperative antiplatelet management of patients receiving dual-antiplatelet therapy after a coronary stent will vary depending on the type of stent and the urgency of the surgery. ASA, acetylsalicylate acid; BMS, bare-metal stent; CABG, coronary artery bypass graft; DES, drug-eluting stent.

Management of minor bleeding. The management of patients on antiplatelet therapy with minor bleeding is outlined and may include further investigation for patients who develop ecchymosis or petechiae. ASA, acetylsalicylate acid.

Management of patients requiring warfarin. The management of patients on antiplatelet therapy requiring warfarin therapy requires an assessment of the risk of bleeding and the medical conditions for which combination therapy may be reasonable. ACS, acute coronary syndrome; ASA, acetylsalicylate acid; BMS, bare-metal stent; DES, drug-eluting stent.

Use of proton-pump inhibitors. The management of patients on dual antiplatelet therapy may include the use of proton-pump inhibitors with minimal inhibition of cytochrome P2C19 in patients considered at increased risk of upper gastrointestinal bleeding. CY, cytochrome; PPIs, proton-pump inhibitors.

Use of NSAIDs in patients on ASA. In patients on ASA, the use on traditional nonsteroidal anti-inflammatory drugs should be avoided and if an anti-inflammatory drug is required, a specific cyclooxygenase-2 inhibitor should be considered. ASA, acetylsalicylate acid; coxib, cyclooxygenase-2 inhibitor; NSAID, non-steroidal anti-inflammatory drugs.