Visual summary Combining antiplatelets and anticoagulants Antiplatelets Oral anticoagulants APL OAC Dual therapy Direct oral anticoagulants For dual antiplatelet therapy, DOAC Monotherapy These are thought to be a safe a P2Y inhibitor can be added: WAR Warfarin ASP Aspirin + 12 alternative to warfarin, although Warfarin is the most there remains uncertainty Aspirin should be prescribed CLO Clopidogrel commonly used about risks versus benefits as the first-line antiplatelet anticoagulant agent unless the patient is PRA Prasugrel intolerant or has a compelling API Apixaban Ticagrelor contraindication TIC Patients should be prescribed the lower licenced dose of a DAB Dabigatran DOAC when combined with Combining novel P2Y12 inhibitors with oral anticolaguants RIV Rivaroxaban increases risk of bleeding, and cannot currently be recommended an antiplatelet Example clinical scenarios 1 Cardiovascular disease 2 Non-valvular atrial brillation Primary prevention Generally, patients who have an acute coronary syndrome and/or undergo percutaneous coronary intervention could benefit from: Antiplatelets are not licensed for the primary prevention of cardiovascular disease. However, ASP there is weak evidence that aspirin may confer 4-6 months ASP CLO OAC some benefit in patients who are hypertensive and Triple therapy + + have impaired renal function or elevated risk of CVD If a patient develops an indication for an OAC, To complete 12 months APL OAC this should replace the antiplatelet agent ASP OAC Dual therapy + Secondary prevention After 12 months Combination and duration Antiplatelet therapy is recommended for the As per secondary depends on stroke risk, bleeding APL secondary prevention of cardiovascular disease prevention of CVD risk, and clinical setting In patients who are at high risk of bleeding, the use of bare-metal If a patient develops an indication for an OAC: stents over drug-eluting stents is recommended to shorten dual Stable coronary Very high risk for antiplatelet and anticoagulant therapy to four weeks. APL artery disease coronary events OAC monotherapy Consider adding aspirin or is recommended clopidogrel to OAC OAC 4 Valvular heart disease instead of OAC antiplatelet + ASP CLO WAR Warfarin is recommended for all patients with native valvular heart disease and atrial fibrillation 3 Deep vein thrombosis Clinical trials for direct oral anticoagulants (DOACs) DOAC in valvular heart disease have not been undertaken DVT in patients prescribed APL OAC Oral anticoagulants are + antiplatelets should be treated with ASP CLO OACs for a minimum of three months + OAC recommended lifelong The addition of an for patients with a antiplatelet reduces risk of mechanical prosthesis In patients with intermediate-to-high bleeding risk, valve thrombosis and Bioprosthetic values might not consider stopping any antiplatelet for the duration arterial thromboembolism APL require oral anticoagulants of the treatment – unless there is an acute but at an increased risk of beyond three months after indication (such as a recent cardiac event) major bleeding insertion © 2017 BMJ Publishing group Ltd. Read the full Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, http://bit.ly/BMJantipc conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of article online treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: http://www.bmj.com/company/legal-information/.