When to use anti platelet vs. anti coag?

[bdc142]

Just got a question in Rx about what drug to use for a pt with afib to prevent thrombosis. The answer was warfarin (instead of heparin or aspirin)...

Can anyone clarify the use of antiplatelet vs. anticoag for prevention of thrombosis?
My impression was that
1) antiplatelet for arterial thromb
2) anticoag for venous thromb

In Goljan pg 120 it defines arterial thrombus as under 1) high velocity vessels and 2) heart chambers and aorta , but apparently it does not apply here?

Any help would be appreciated - thanks.

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[Apoplexy__]

Just got a question in Rx about what drug to use for a pt with afib to prevent thrombosis. The answer was warfarin (instead of heparin or aspirin)...

Can anyone clarify the use of antiplatelet vs. anticoag for prevention of thrombosis?
My impression was that
1) antiplatelet for arterial thromb
2) anticoag for venous thromb

In Goljan pg 120 it defines arterial thrombus as under 1) high velocity vessels and 2) heart chambers and aorta , but apparently it does not apply here?

Any help would be appreciated - thanks.

Patients with a-fib need long-term outpatient therapy with warfarin. The stasis in the atria predisposes to mural thrombi in an analogous way to DVT's. This has nothing to do with endothelial injury, atherosclerosis, etc. which is where antiplatelets often come into play. Heparin can be used as a bridge to warfarin and in the inpatient setting, but these patients need long-term oral anticoagulants. As a general rule, heparin is used when you want quick anticoagulation for a short range of time; you don't put patients on heparin long-term because they'll get osteoporosis.

Warfarin use in atrial fibrillation is a huge, huge point and is a must-know for the rest of your career.

As a memorable aside, my internal medicine preceptor, upon being told that a patient was on warfarin, would immediately ask "for DVT or a-fib?". That's how your mind should associate long-term warfarin.

 

[Suture15]

The reason that was warfarin is because you're preventing i.e it is prophylaxis. For long term prophylaxis, consider warfarin as an answer always.

I personally have never heard of the distinction between arterial/venous thrombi in terms of pharm, I just use specific scenarios that are listed in FA (they show up in uworld also)

So for example if it's a DVT - Heparin or FactorXa inhibitors --> and by extension you can use them for pulmonary emboli also
Acute coronary events, go with heparin unless there is info to the contrary
Pregnancy avoid warfarin
Stroke or early MI - go with thrombolytics but make sure you check for haemorrhage first!
TIAs - ADP receptor inhibitors/PDE5 inhibitors
Post interventional - GPIIb/GPIIIa inhibitors

A lot of times they will either try to describe the mechanism to you or give some contraindication or something.

 

[bdc142]

I think that definitely clarifies it for afib but can guys you go into more (whether that be clinical experience or questions) when exactly should anti-platelet therapy be used?

THanks for the replies!

 

[seminoma]

I think that definitely clarifies it for afib but can guys you go into more (whether that be clinical experience or questions) when exactly should anti-platelet therapy be used?

THanks for the replies!

Other than ACS and PCI/stenting you are very likely going to use an anticoagulant.

 

[Instatewaiter]

The reason that was warfarin is because you're preventing i.e it is prophylaxis. For long term prophylaxis, consider warfarin as an answer always.

I personally have never heard of the distinction between arterial/venous thrombi in terms of pharm, I just use specific scenarios that are listed in FA (they show up in uworld also)

So for example if it's a DVT - Heparin or FactorXa inhibitors --> and by extension you can use them for pulmonary emboli also
Acute coronary events, go with heparin unless there is info to the contrary
Pregnancy avoid warfarin
Stroke or early MI - go with thrombolytics but make sure you check for haemorrhage first!
TIAs - ADP receptor inhibitors/PDE5 inhibitors
Post interventional - GPIIb/GPIIIa inhibitors

A lot of times they will either try to describe the mechanism to you or give some contraindication or something.

DVT/PE- Heparin/Low-molecular weight heparin bridge to coumadin or novel anticoagulants (factor X or direct thrombin)

Acute coronary events- heparin + Aspirin + plavix/ticagrellor/prasugrel + Cath. Early MI DOES NOT get thrombolytics unless it is a STEMI and you are in the middle of nowhere and can't send them to a PCI capable facility

Stroke- early on use thrombolytics if ischemic

TIA- plavix

Post-intervention- they don't use IIb/IIIa inhibitors commonly anymore.