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Freek W.A. Verheugt

The Antiplatelet Sub-study of RE-LY. Discussion. Freek W.A. Verheugt. Department of Cardiology, Onze Lieve Vrouwe Gasthuis . Amsterdam, The Netherlands. Disclosures for Freek W.A. Verheugt. Antiplatelet vs. No antiplatelet: Bleeding. Hemorrhagic Stroke. DE 110. Major Bleed. DE 150.

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Freek W.A. Verheugt

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  1. The Antiplatelet Sub-study of RE-LY Discussion Freek W.A. Verheugt Department of Cardiology, Onze Lieve Vrouwe Gasthuis Amsterdam, The Netherlands

  2. Disclosures for Freek W.A. Verheugt

  3. Antiplatelet vs. No antiplatelet: Bleeding Hemorrhagic Stroke DE 110 Major Bleed DE 150 Warfarin Minor Bleed Major/Minor Bleed + 60% Intracranial Extracranial Dans AL. ESC 2011 0.1 0.2 0.5 1.0 2.0 5.0 10.0

  4. Non-fatal and FatalBleeding n = 82,854 Hansen ML. Arch Intern Med 2010;170:1433-1441

  5. Non-fatal and Stroke n = 82,854 n = 82,854 Hansen ML. Arch Intern Med 2010;170:1433-1441

  6. ESC Guideline on AF Eur Heart J 2010;31:2369-2429

  7. ESC Guideline on AF Eur Heart J 2010;31:2369-2429

  8. USA Suggestion Eikelboom J. Circulation 2010;121:2067-2070

  9. DE 110 vs Warfarin Stroke/Embolism Non-inferiority margin= 1.46 All Stroke Hemorrhagic Ischemic CV Death Major Bleed Minor Bleed All Bleed No Antiplatelet Intracranial Antiplatelet Extracranial Dans AL. ESC 2011 0.1 0.2 0.5 1.0 2.0 5.0 10.0

  10. DE 150 vs Warfarin Stroke/Embolism Non-inferiority margin= 1.46 All Stroke Hemorrhagic Ischemic CV Death Major Bleed Minor Bleed All Bleed No Antiplatelet Intracranial Antiplatelet Extracranial Dans AL. ESC 2011 0.1 0.2 0.5 1.0 2.0 5.0 10.0

  11. WOEST 496 patients on OAC undergoing stent (DES/BMS) implantation randomization oral anticoagulants* oral anticoagulants* + + clopidogrel 75 mg qd** clopidogrel 75 mg qd** + aspirin 80 mg qd Follow-up: 12 months * INR as originally indicated Primary endpoint: bleeding ** BMS 1 month Secondary endpoint: ischemic events DES 1 year Dewilde W, Ten Berg JM. Am Heart J 2009;158:713-718

  12. ISAR-Triple 600 patients on OAC undergoing DES randomization 6 weeks 6 months oral anticoagulants* oral anticoagulants* + + clopidogrel 75 mg qd clopidogrel 75 mg qd + + aspirin 80 mg qd aspirin 80 mg qd oral anticoagulants + aspirin Follow-up: 9 months * INR as originally indicated Primary endpoint: ischemic events + bleeding Secondary endpoint: ischemic events, bleeding Schömig A. Heart 2009;95:1280-1285

  13. MUSICA-2 300 patients with AF (CHADS2 ≤ 2) on OAC undergoing stenting randomization 6 months 6 months oral anticoagulants* clopidogrel 75 mg qd clopidogrel 75 mg qd + + + aspirin 100 mg qd aspirin 300 mg qd Follow-up: 12 months * INR as originally indicated Primary endpoint: ischemic events + death Secondary endpoint: major and minor bleeding clinicatlrials.gov NCT01141153

  14. Novel Anticoagulants and Dual Antiplatelet Therapy Conclusions-1 1. In RE-LY triple therapy (OAC, ASA and clopidogrel) increases major bleeding by 60% irrespective the anticoagulant used 2. The ischemic AND bleeding benefit of dabigatran over warfarin is maintained with antiplatelet therapy 3. The lowest rate of ICH in this study is seen with low dose dabigatran, which is even lower than with warfarin without antiplatelets

  15. Novel Anticoagulants and Dual Antiplatelet Therapy Conclusions-2 Low dose dabigatran seems a good candidate for patients with AF in the need of antiplatelet therapy (e.g, stenting and/or ACS), but this has to be confirmed in a new randomized trial against warfarin. However, it is unlikely, that such a trial will be done 4.

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