The Role of Factor Xa Inhibitors in the Management of CAD/PAD - Episode 6

Chronic CAD/PAD Versus Acute Coronary Syndrome

December 13, 2019

Deepak L. Bhatt, MD, MPH: We’ve talked a lot about chronic disease so far, either subclinical, overt coronary disease, peripheral artery disease, and even a little bit about cerebrovascular disease. European guidelines recently introduced a term, chronic coronary syndrome. So I thought it was pretty clever. For people who have coronary disease, it’s stable, but it’s a bit of a misnomer to stay it’s stable coronary disease. It’s just a chronic phase of things.

But of course, the flip side of that is acute coronary syndrome [ACS]. That is when people are coming in with heart attacks, either ST-segment elevation MI [myocardial infarction], non—ST-segment elevation MI, potentially unstable angina, which is still out there. Let’s talk a little bit about acute coronary syndrome as it pertains to primary care, in particular, and the management, not so much the acute management. That’s often driven by a cardiologist or some other type of specialist. But if a patient had ACS, and now they’re seeing their primary care physician a week later—that actually would be really good if they see them a week later—what do they need to think about?

Vamsi Krishna, MD: This is my life every day. We do a case and it’s an acute event. I think the biggest thing that has come about is a lot of buzz about aspirin, a lot of buzz about duration of antiplatelet therapy. The term DAPT [dual antiplatelet therapy] is what you hear in the media. And so the biggest thing that I try to parse out in my note is to help them identify, what is the strategy for this next year? And it’s a continued risk. Our first year we know is the “highest” risk. So what’s our plan going to be? And after that acute plan, how are we going to decrease the risk going forward? And so I try to outline that for the primary care physician and have that conversation with them to help them understand, especially with all these new trials coming out, with global leaders, and with TWILIGHT. And there’s a lot of buzz about stopping aspirin, starting aspirin. And my population is similar to yours, they all have AFib [atrial fibrillation], CKD [chronic kidney disease], and other complex issues. So it becomes, for the primary care provider, what do we do with all this polypharmacy?

Deepak L. Bhatt, MD, MPH: It’s confusing for the cardiologist.

Vamsi Krishna, MD: It’s confusing for everyone, including the patient. And they get discharged on multiple medications. So I think 2 things. I think AI [artificial intelligence] is honestly going to help us both for detection, what you were mentioning before, of who’s at risk. Artificial intelligence and machine-based learning. I think it’s going to be really important to help solve some of these problems because even with the best trained systems, we’re still making a lot of errors in these areas. And so in our system, we luckily have 5000 physicians, so there’s at least a network where we’re able to contact providers and information is flowing. And supposedly it’s a seamless network, which is still not seamless. But I think the biggest thing is the duration of antiplatelet therapy, and the use of lipid-lowering agents is critical. And I think from a cardiologist perspective, I want to make sure that I’m giving them appropriate guidance.

Deepak L. Bhatt, MD, MPH: When is that transition from chronic to acute or vice versa, how do we define that? Is it the time? Is it the place? Is it a state of mind?

Manesh Patel, MD: It’s complicated. It’s a state of mind. But I think in general, what you’re saying and what is important to remember is that the primary care physician, when they see a patient who has had a heart attack, an acute coronary syndrome, first and foremost, that’s an opportunity. It’s gotten so where you’ll do your procedure, and that patient will be in the hospital 2-and-a-half days in the United States, but let’s say 5 days in the world. The median time used to be longer. They see somebody say in 7 to 15 days, and it’s gone from you having had a heart attack to, “OK, back to work, what are we going to do?”

So I think the chronic and the acute coronary syndrome conversation is first to highlight that their risk is not going down. I guess in a very existential way, from the time you’re born to the time you die, your risk is going up, right? But when you’ve had that heart attack, it might be a moment for people to say, “You’ve had an event that’s really important.” And to get back to the 3-legged stool of how you are going to take care of these patients, clearly now your cholesterol and blood pressure recommendations are going to change. If you weren’t at your best goal with blood pressure, you’re really going to do it with certain agents. If you weren’t at best goal with cholesterol, with a lipid, you’re going to do it.

The second point is now, there’s a really big emphasis on antithrombotic therapy. And traditionally, still about 60% or half of patients with non-STEMI [non—ST-segment elevation myocardial infarction] don’t get a stent. We could talk about them. And then in the setting of STEMI, it’s higher. For those who have been stented, thankfully good interventionalists and others will give you some guidance, there’s going to be dual antiplatelet therapy. The clinical trials in general had those patients go through that therapy for 1 year.

So I would say the acute phase, based at least on most of the clinical trials for 2 antiplatelet therapies—aspirin plus clopidogrel, aspirin plus ticagrelor, aspirin plus prasugrel—those trials were 1 year. So when the physician sees that patient at 7, 14 days, the goal is to say, are you taking both? Are you aware you need to take both? You’re going to see me in 3 months or 6 months. We’re going to talk about if you have to keep going, but how do you contact me? That’s, I think, an important point for us most of the time.

So take a moment to say, “Hey, this is important,” get to the new spectrum. And then follow what’s likely been said, somebody said, “Hey, you should do this for a year or 6 months, because I think it can be shorter,” or if they have a bleeding event, these are things to consider. And I think that’s really great communication. I wish I always did that well. But that would be another way to, I think, point that out.

Deepak L. Bhatt, MD, MPH: Well, a lot of that should be a health system technician. It’s tough as an individual always to carry through.

Manesh Patel, MD: To remember everything.

Transcript edited for clarity.