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June 21, 2024

An AMDA On-The-Go podcast recorded during PALTC24 in San Antonio, TX—Deprescribing of Anticoagulants: The IF, WHEN and HOW—featured clinical pearls and more from Sabine von Preyss-Friedman, MD, FACP, CMD; Nicole Orr, MD; and Irene Hamrick, MD, CMD. Here are just a few of the many insights from the program:

  • There is no protection for embolic stroke from atrial fibrillation with aspirin alone, and cardiology and internal medicine have moved away from that strategy of stroke prevention over the last several years. If someone has documented atrial fibrillation and the mechanism is going to be a cardioembolic event, the only way to reduce the risk of primary or secondary stroke is with systemic anticoagulation. 
  • In patients with atrial fibrillation, anticoagulation decreases the development of dementia dramatically. If patients or families are hesitant to start anticoagulation for AFib for fear of bleeding or other reasons, talking about the reduced risk of dementia often convinces them. 
  • The 2023 chronic coronary disease guidelines emphasize minimizing the duration of triple therapy as much as possible. For patients who require a PCI for atrial fibrillation or other indication for anticoagulation, the guidelines now recommend one to four weeks only of triple therapy and one week for patients who are at extremely high risk of bleeding but potentially lower risk of thrombotic events and four weeks for patients who are at higher risk for thrombotic events but lower risk of bleeding. That time period of between one and four weeks is determined by shared decision-making based on the patient's individual risk. 
  • Clinicians are really trying to minimize the overlap of the duration of antithrombotic therapy in all patients, not just older adults and nursing home residents. 
  • Anticoagulation stewardship, defined as a coordinated, efficient, and sustainable system-level initiative designed to achieve optimal anticoagulation-related health outcomes, is a concept whose time has come. It should optimally include a very high emphasis on avoiding triple therapy whenever possible.  
  • As part of a deprescribing effort, the physician, pharmacist, and other members of the deprescribing team should look at every antithrombotic therapy and see whether it has an appropriate indication for anticoagulation. This should be a first step and can be done very efficiently. In fact, it is possible to start an antithrombotic stewardship program with a five-minute phone conversation with the pharmacist.
  • Stewardship is a powerful tool, as anticoagulants are life savings for individuals with cardiac and vascular disorders and reduce the risk of stroke with atrial fibrillation by as much as 62% and the risk of embolism and recurrence in patients with venous thromboembolism. At the same time, anticoagulants are increasingly recognized as a population health problem; according to the Anticoagulation Forum, these agents are the number one drug class associated with adverse drug events—accounting for over 1.2 million emergency department visits in over five years. About 80% of those visits occurred in patients over 65 years of age, and half of those ED trips resulted in hospitalization.

Listen to the full podcast now and get more insights from this panel of experts.