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CV Update – Guidelines & DebatesCV Update – Guidelines & DebatesRoyal Pharmaceutical Society, Great Britain Royal Pharmaceutical Society, Great Britain
Barnet – 27/01/09Barnet – 27/01/09
Dr Ameet Bakhai, FRCP
– Cardiologist, Clinical Trials, Health Economics
Barnet & Chase Farm NHS Trust
Royal Free NHS Trust, University of Hertfordshire
Bushey Spire
Conflict of Interest: Consultant to companies, Research Grants
Work with NICE, AMORE Health, Health Smart UK
Atherothrombosis Significantly Shortens
Life Expectancy (Prognosis) at 60
Framingham Heart StudyPeeters et al. Eur Heart J 2002; 23: 458–466
Healthy History of Angina
History of MI
History of CVA
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www.nclcn.org.uk
Oral Anti-Platelet Therapy Maintenance for Cardiovascular Risk / Disease v2.0 DraftProduced by NCL CVD Prevention Task Group primary author Dr Ameet Bakhai- Review Date Jan 2010.
NCL Cardiac and Stroke Network
Ischaemic Stroke/TIA (no AF)Dipyridamole SR 200mg bd 2 years plus Aspirin 75mgs daily
OrAspirin 75mg daily (for patients
intolerant to dipyridamole)Or
Clopidogrel 75mgs daily for aspirin allergic patients
Recurrent Strokes / TIAs (no AF)(whilst on aspirin and dipyridimole)
No evidence base to provide guidance on changing to different anti-platelet agent
ST elevation MI without stentAspirin 75mg daily
Clopidogrel 75mg daily 12 months*
ST elevation MI with stentAspirin 75mg daily
Clopidogrel 75mg daily for 12 months*
Non-ST elevation MI / Unstable angina with / without stent
Aspirin 75mg dailyClopidogrel 75mg daily for 12 months*
Chronic Stable Angina without recent event (>12 months) / Peripheral Arterial Disease
Aspirin 75mg daily
Drug Eluting Stent with / without MIAspirin 75mg daily
Clopidogrel 75mg daily for 12 months*
Bare Metal Stent with / without MI / UAAspirin 75mg daily
Clopidogrel 75mg daily for 4 weeks*
Patient on Aspirin with GI symptoms or previous ulcer with either age ≥ 60 or also using another anti-platelet / warfarin / corticosteroids/ NSAIDs / SSRIs should have PPI cover.^
Ensure medication is taken with food. Eradicate H Pylori as needed. Add Lansoprazole 30mg / Omeprazole 20mg daily (check outcome).
Patient with a new gastro-intestinal bleed
Discontinue aspirin and clopidogrel. Liaise with cardiologist
and gastroenterologist urgently
Aspirin Allergy
(bronchospasm or angio-oedema) or rash, associated with administration of aspirin
Clopidogrel 75mg
Asymptomatic, Age≥50,
10 year CVD risk ≥20%
Aspirin 75 mg daily after Baseline BP≤150 / 90
Asymptomatic with Diabetes Mellitus (I or II) with any of:Age≥40 / metabolic syndrome /≥10 year DM / HbA1c≥9% / Tchol ≥
6mmol/l / on drugs for BP / organ damage / family history of premature coronary disease (M≤55, F≤65)
Aspirin 75 mg daily after Baseline BP≤150 / 90
* In certain situations cardiologist may specify
shorter or longer clopidogrel duration
Primary Secondary
When anti-platelet therapy is initiated in secondary care a clear written indication, which includes duration, should be recorded and communicated to primary care. Where a duration is NOT specified it is assumed the drug is to be continued long term. For complex patients not covered by these simplified guidelines - please contact the supervising consultant or Dr A Bakhai to assist. Ensure duration of therapy is flagged on GP’s clinical notes if NOT for long term. Recommend for clopidogrel – patients issued a clopidogrel patient card. For aspirin - enteric aspirin does not appear to confer advantage #..
References: NICE – Vascular Disease guidance TA090NICE – NSTE -ACS guidance TA080NICE – Post MI guidance (Mar 07)Joint British Society Guidance 2 (2005). Clopidogrel 12 mths – local consensus. ^Circulation 28.10.08 #National Prescribing Centre MeReC Bulletin 2005;15
Atrial fibrillation pts for antithrombotic but not for anticoagulants: warfarin
Aspirin 75 mg daily after Baseline BP≤150 / 90
United Kingdom Clinical Pharmacy Association (cardiac group) Clopidogrel Patient Cardhttp://www.ukcpa.org/?pid=0&lsid=3593&edname=22554.htm&ped=22554