From the Guidelines
For this 73-year-old female with Factor V Leiden deficiency, atrial fibrillation, recent NSTEMI, prior STEMI with stents, and superior mesenteric artery clot, the long-term antiplatelet plan should focus on balancing thrombotic and bleeding risks. I recommend continuing warfarin (target INR 2-3) indefinitely for both the Factor V Leiden deficiency and atrial fibrillation, as supported by the guidelines 1. Aspirin 81mg should be discontinued after 1 month from the NSTEMI, as the patient is already on anticoagulation with warfarin, to minimize the risk of bleeding, which is a concern especially in elderly patients 1. The ticagrelor should be continued for a total of 12 months post-NSTEMI, then discontinued, as recommended for patients with UA/NSTEMI treated with a stent or medically without stenting 1.
This approach provides necessary antithrombotic coverage while minimizing bleeding risk. The rationale is that triple therapy (warfarin, aspirin, and ticagrelor) carries excessive bleeding risk, especially in an elderly patient. Warfarin addresses both the hypercoagulable state from Factor V Leiden and stroke prevention in atrial fibrillation, while the P2Y12 inhibitor (ticagrelor) provides necessary post-ACS platelet inhibition. Regular monitoring of INR is essential, and the patient should be evaluated for bleeding risk at each follow-up visit.
Key considerations in this plan include:
- The patient's history of atrial fibrillation and Factor V Leiden deficiency, which necessitate long-term anticoagulation with warfarin 1.
- The recent NSTEMI and prior STEMI with stents, which require antiplatelet therapy to prevent further ischemic events 1.
- The need to balance thrombotic and bleeding risks, particularly in an elderly patient, by selecting the appropriate duration and combination of antithrombotic therapies 1.
From the FDA Drug Label
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 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
The long-term antiplatelet plan for this patient is aspirin in combination with warfarin for at least 3 months after the non-ST elevation myocardial infarction (NSTEMI), considering the patient's history of myocardial infarction, atrial fibrillation, and factor V Leiden deficiency.
- The patient should continue on low-dose aspirin (≤100 mg/day) in combination with moderate-intensity warfarin (target INR, 2.0 to 3.0).
- Aspirin can be ceased after 3 months, but this decision should be made on a case-by-case basis, taking into account the patient's individual risk factors and clinical presentation 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 bridged to warfarin with heparin infusion.
- Considering the patient's history of STEMIs and stents, dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor may be recommended for at least 12 months after the acute coronary syndrome (ACS) event 3.
- However, the benefits and risks of prolonged DAPT beyond 1 year should be carefully evaluated, taking into account the patient's thrombotic and bleeding risks 3, 4.
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.
- Studies have shown that the risk of major bleeding increases with age, particularly in patients over 75 years old 5.
- The patient's history of factor 5 Leiden deficiency and AF may also increase their risk of bleeding.
- However, the patient's history of STEMIs and stents may also increase their risk of ischemic events, and aspirin may be beneficial in reducing this risk 3, 6.
- A careful evaluation of the patient's thrombotic and bleeding risks should be performed to determine the optimal duration of aspirin therapy 3, 4.
Considerations for Triple Antithrombotic Therapy
The patient is currently on warfarin, aspirin, and triglecor, which is a form of triple antithrombotic therapy.
- Studies have shown that triple antithrombotic therapy with aspirin, a P2Y12 inhibitor, and warfarin can increase the risk of bleeding, particularly in patients with a history of bleeding or at high risk of bleeding 7.
- The patient's history of factor 5 Leiden deficiency and AF may increase their risk of bleeding, and the benefits and risks of triple antithrombotic therapy should be carefully evaluated 7, 5.