What is the long-term antiplatelet plan for a 73-year-old female with a history of Superior Mesenteric Artery (SMA) thrombosis, Non-ST-Elevation Myocardial Infarction (NSTEMI), Factor V Leiden mutation, Atrial Fibrillation (AF), previous ST-Elevation Myocardial Infarction (STEMI) with stent placement, currently on Heparin infusion being bridged to Warfarin, Aspirin, and Triglyceride-lowering medication (Triglecor), 10 days post-NSTEMI?

From the Guidelines

For this 73-year-old female with complex thrombotic history, the recommended long-term antiplatelet plan would be to continue warfarin for her atrial fibrillation and Factor V Leiden deficiency, while discontinuing aspirin after 1-3 months following her NSTEMI. Given her recent SMA clot, NSTEMI, history of STEMI with stents, and hypercoagulable state, she requires careful antithrombotic management. Warfarin should be targeted to an INR of 2.0-3.0 for long-term anticoagulation, as recommended by the guidelines 1. Aspirin (81mg daily) should be continued for 1-3 months post-NSTEMI, then discontinued to reduce bleeding risk while maintaining adequate antithrombotic protection with warfarin alone. Ticagrelor should be discontinued as it adds significant bleeding risk without clear benefit in her case once stabilized on warfarin. This approach balances her high thrombotic risk from multiple conditions against bleeding concerns. Regular monitoring of INR is essential, and the patient should be educated about bleeding signs and when to seek medical attention.

Some key points to consider in her management include:

• The use of warfarin for long-term anticoagulation, with a target INR of 2.0-3.0, as recommended by the guidelines 1
• The discontinuation of aspirin after 1-3 months post-NSTEMI to reduce bleeding risk, while maintaining adequate antithrombotic protection with warfarin alone
• The discontinuation of ticagrelor due to its significant bleeding risk without clear benefit in her case once stabilized on warfarin
• Regular monitoring of INR and patient education on bleeding signs and when to seek medical attention

It's also important to note that the guidelines recommend the use of beta blockers for all patients recovering from UA/NSTEMI unless contraindicated 1, and that aspirin should be prescribed indefinitely for patients treated medically without stenting, while clopidogrel or ticagrelor should be prescribed for up to 12 months 1. However, in this case, the patient's complex thrombotic history and hypercoagulable state require a more tailored approach, prioritizing the use of warfarin for long-term anticoagulation.

From the FDA Drug Label

The results of the WARIS II study and 7th ACCP guidelines suggest that in most healthcare settings, moderate- and low-risk patients with a myocardial infarction should be treated with aspirin alone over oral vitamin-K antagonist (VKA) therapy plus aspirin In healthcare settings in which meticulous INR monitoring is standard and routinely accessible, for both high- and low-risk patients after myocardial infarction (MI), long-term (up to 4 years) high-intensity oral warfarin (target INR, 3.5; range, 3.0 to 4.0) without concomitant aspirin or moderate-intensity oral warfarin (target INR, 2.5; range, 2.0 to 3. 0) with aspirin is recommended. For high-risk patients with MI, including those with a large anterior MI, those with significant heart failure, those with intracardiac thrombus visible on echocardiography, and those with a history of a thromboembolic event, therapy with combined moderate-intensity (INR, 2.0 to 3. 0) oral warfarin plus lowdose aspirin (≤100 mg/day) for 3 months after the MI is suggested.

The patient has a history of NSTE MI, AF, and Factor V Leiden deficiency. Given the patient's high-risk profile, the long-term antiplatelet plan would likely involve aspirin in combination with warfarin.

• The patient should be on low-dose aspirin (≤100 mg/day) for at least 3 months after the MI, in combination with moderate-intensity warfarin (target INR, 2.0 to 3.0) 2.
• After 3 months, the decision to continue or cease aspirin should be based on the patient's individual risk-benefit assessment, taking into account their history of MI, AF, and thrombophilic condition.
• The patient's warfarin therapy should be continued indefinitely, with regular monitoring of INR levels to ensure therapeutic range (2.0 to 3.0) 2.

From the Research

Long-term Antiplatelet Plan

The patient's long-term antiplatelet plan should be tailored to their individual risk factors, including their history of factor 5 Leiden deficiency, atrial fibrillation (AF), and previous STEMIs with stents 3.

• The patient is currently on aspirin and triglecor, and has been on heparin infusion being bridged to warfarin for 10 days after the NSTEMI.
• According to the study by 3, dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is recommended for at least 12 months after acute coronary syndrome (ACS).
• However, the study by 4 suggests that for patients at high risk of both ischemia and bleeding, clopidogrel monotherapy may be a better option than DAPT, with a significant net clinical benefit.

Aspirin Cessation

The decision to cease aspirin should be based on the patient's individual risk factors and the balance between the benefits and risks of antiplatelet therapy.

• The study by 5 found that the risk of recurrent ischemic events and major bleeding increases in parallel, and that antiplatelet treatment cannot be individualized solely based on bleeding risk assessment.
• The study by 6 found that the risk of major bleeding, particularly fatal bleeds, increases steeply with age, and that the estimated number needed to treat (NNT) for routine proton-pump inhibitor (PPI) use to prevent disabling or fatal upper gastrointestinal bleeds is low in older patients.
• The study by 7 found that triple antithrombotic therapy with aspirin, P2Y12 inhibitor, and warfarin is associated with a significant excess of bleeding, and that the use of higher potency P2Y12 inhibitors should be used cautiously in these patients.
• The study by 4 found that clopidogrel monotherapy demonstrated a significant net clinical benefit compared to DAPT, with numerical reductions of bleeding and ischemic event rates compared to aspirin monotherapy.

Considering these findings, the patient's aspirin therapy may be ceased and replaced with clopidogrel monotherapy, taking into account their individual risk factors and the balance between the benefits and risks of antiplatelet therapy 4. However, this decision should be made on a case-by-case basis, and in consultation with the patient's healthcare provider.