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Hi, everyone. Doctor Reimer and it's, it's nice to be here today. I'm going to be presenting individualizing antithrombotic and antiplatelet uh strategies in atrial fibrillation. Here are my disclosures, uh, of notes. I do have relationships with KAC Adorcia Pharmaceuticals, um, in research investigator, uh, purposes. All right. So learning objectives, uh, we're going to individualize antithrombotic. Therapy selection and dosing to maximize efficacy while mitigating risk, and we're gonna focus on coronary artery disease, some other cardiovascular diseases, uh, we're gonna focus on acute coronary syndromes and atrial fibrillation. So one of the big, uh, areas to focus on, we have to optimize DOAC dosing and selection to ensure stroke prevention without increasing bleeding risk. That's a big issue for these patients, uh, reducing underuse and inappropriate substitution. We want to address barriers to adherence, um, and improve patient engagement with a specific focus on shared decision making. So how to talk with patients about anticoagulation and helping them make these decisions. And then we wanna reduce inappropriate modifications of anticoagulant therapy due to bleeding concerns. There's a lot of issues around perceived increased bleeding risk but not also perceiving the patient's thrombotic or um stroke risk. So here's a case presentation. So this was a patient I took care of, um, 64 year old female with history of ESRD on dialysis, severe peripheral artery disease, uh, with multiple interventions, amputation of multiple fingers, toes, um, secondary to ischemia. She has coronary artery disease, um, and had multiple PCIs or percutaneous coronary interventions, and unfortunately had a prior stroke, um, secondary to her atrial fibrillation. So with previous PTY12 inhibitor cessation, she's had stent thrombosis, unfortunately. She's failed multiple statins due to myalgias or muscle aches. Um, she came in presenting with chest pain over the past several weeks. Um, she describes chest tightness with any exertion with increasing frequency, um, of, of occurrence. So here are the presenting angiograms, which you can see. that both in the LAD distribution, um, and in the circumflex distribution, you can see that there is, um, stent thrombosis, um, or in stent restenosis, and, and she has multiple layers of stent in, um, both distributions. And so was having chest tightness, um, multiple stents already. Um, and I told you already a previous history of stroke, so a high risk of having a recurrent stroke. So, tough to figure out what the right regimen for this patient is. Um, she's had, I told you she's had recurrent episodes of stent thrombosis, so she may need more potent antiplatelet therapy. Traditionally, we would think about ticagrelor or prazagrel in a patient like this um to achieve more potent antiplatelets or platelet rather inhibition. I told you she had atrial fibrillation with the previous stroke history. Um, so she really needs to be on some form of, of anticoagulation, uh, whether it be warfarin or one of the, um, direct oral anticoagulants continuously. But there may be bleeding with her, um, with her end-stage renal disease. We know that end-stage renal disease confers a higher risk of both bleeding and thrombosis, so this is an issue to consider. Do we do triple therapy or not? So after I intervene on both her LAD and circumflex arteries, do I put her on aspirin and antiplatelet therapy like prazagrel or ticagrelor that's more potent with an oral anticoagulant, and what kind of bleeding risk is that conferred for her? And she needs future surgical interventions. Unfortunately, she was diagnosed with breast cancer and needed a mastectomy. Um, does she need a kangle or bridge when she comes into the hospital to wash out the antiplatelet therapies, or can she simply cease the antiplatelet therapy for the requisite number of days prior to her surgery? Does she need heparin? And so I think all of these are very complex decisions to try to make with the patients, um, and it's not a decision that the provider can make in a vacuum. Uh, these decisions need to be made with the patient in terms of shared decision making, talking to them about the bleeding risk versus the thrombosis risk, and getting a sense for what their preferences, uh, for their lifestyle for risk are. And so this was a big consideration for this patient. So atrial fibrillation with concomitant percutaneous coronary interventions and coronary artery disease. These are common issues that I have to talk with the patient about and consider. So when patients come in and um they are either on an oral anticoagulant coming into a potential intervention and a need for a heart catheterization, Um, need to, to think about, um, uh, appropriateness of the PCI procedure, um, when to perform it. So if they come in and they're still taking their oral anticoagulant, giving a requisite amount of time, if it's not urgent or emergent to then do the procedure and obtain vascular access, um, in terms of afterwards, a lot of conversations on what to do subsequently. So if the patient underwent percutaneous coronary intervention and has atrial fibrillation, Um, then you would want to start them back on for a period, what's called triple therapy, which is aspirin and antiplatelet agents, um, like a P2Y12 inhibitor, and then a direct oral anticoagulant. And so typically, we do around a week to a month of triple therapy in patients with concomitant, um, atrial fibrillation with a recent percutaneous coronary intervention. And we do a combination like clopidogrel and apixaban subsequently thereafter. Now, it's very important to make sure that your direct oral anticoagulant is appropriately dosed and that you think about the duration of um the need for PTY12 inhibitor therapy um during this time period. So does the patient need it for 6 weeks or 6 months or a year potentially if it's an acute coronary syndrome. Those are all considerations that need to be had, as well as thinking about the use of PPIs, so proton pump inhibitors, if you're concerned for the possibility of gastric ulcers. So dept, duration, and de-escalation. So dualny platelet therapy, duration and de-escalation. NICE um publication in Jack of 2018. Um, looking at the different, uh, duration strategies based on the patient's high bleeding risk. So if they have a high bleeding risk and stable coronary disease, typically you're thinking about potentially ceasing therapy around 1 to 3 months, really depending on Um, uh, you know, their, how severe their bleeding risk is. We don't really use bare metal stents anymore. We primarily use drug-eluting stents. So many of us are comfortable on very high bleeding risk patients that had stable coronary disease, for instance, ceasing the PTY12 inhibitor at around 6 weeks to 3 months. Uh, for patients with no high bleeding risk, you can feel a little bit more comfortable extending for a longer period of time to say 6 months. Now, for, uh, patients with acute coronary syndromes, typically, you still wanna think about with no high bleeding risk, trying to follow the guidelines with dny platelet therapy out to a year. For those with high bleeding risk, you may be able to consider cessation at 6 months. All of these things and all of these considerations are on a patient by patient basis and should be, um, discussed with the patient in terms of their history and potential consequences. And uh mitigation of thrombosis versus bleeding. Atrial fibrillation with concomitant peripheral artery disease considerations. So these patients are at the very high risk. Patients with peripheral artery disease, very high risk of ischemic complications. So those patients with high bleeding risk, you may wanna consider antiplatelet monotherapy, either aspirin alone or an agent like clopidogrel alone. If you can accept, um, their bleeding risk, if they have an acceptable bleeding risk, and they have what's called either a high male or high MCE risk, so MAIL stands for major adverse limb event risk, so risk for future amputation, they have a high major adverse cardiovascular risk. Um, those patients you may want to consider, for instance, long-term DPI. So that would be an agent like low-dose rivaroxaban, and I use those in many of my patients that have high risk for these cardiovascular events or these limb events. Um, in patients with a lower risk, you may just be able to use antiplatelet monotherapy.