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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EPatients with non-ST-elevation (NSTE) acute coronary syndrome (ACS) are treated with antiplatelet and anticoagulation to reduce ischemic complications [Hamm CW et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2011; Wright RS et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2011]. This article discusses selecting the appropriate therapies and improving short- and long-term outcomes in patients with NSTE-ACS.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECoronary Artery Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECoronary Artery Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EPatients with non-ST-elevation (NSTE) acute coronary syndrome (ACS) are treated with antiplatelet and anticoagulation to reduce ischemic complications [Hamm CW et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2011; Wright RS et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2011]. The presentations in this session focused on selecting the appropriate therapies and improving short- and long-term outcomes in patients with NSTE-ACS.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECHOOSING THE BEST ANTITHROMBIN THERAPY\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EMarco Valgimigli, MD, PhD, Erasmus Medical Center, Rotterdam, The Netherlands, reviewed the evidence on anticoagulants for patients with NSTE-ACS. The anticoagulants, unfractionated heparin (UFH), enoxaparin, and fondaparinux are recommended for patients with NSTE-ACS regardless of whether an early invasive or conservative strategy is chosen. In constrast, bivalirudin is only indicated for patients who are being considered for revascularization with an early invasive strategy [Hamm CW et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2011; Wright RS et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EA meta-analysis of six trials reported an initial 50% relative risk reduction (RRR) in myocardial infarction (MI) or death and a 2-fold increase in major bleeding in patients treated with UFH plus acetylsalicylic acid (ASA) versus ASA alone. After 12 weeks the RRR decreased to 33% [Oler A et al. \u003Cem\u003EJAMA\u003C\/em\u003E 1996]. Results of other UFH studies are shown in \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15878\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15878\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15878\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003EStudies of Unfractionated Heparin\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EIn OASIS-5 [Yusuf S et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2006], fondaparinux was noninferior to enoxaparin for reducing ischemic events at 9 days but significantly reduced mortality by 17% (HR, 0.83; 95% CI, 0.71 to 0.97; p=0.02) and bleeding by 50% (HR, 0.52; 95% CI, 0.44 to 0.61; p\u0026lt;0.001).\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EThe ACUITY trial [Stone GW et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2006] reported that for patients receiving percutaneous coronary intervention (PCI), bivalirudin plus provisional glycoprotein IIb\/IIIa inhibitor (GPI) was noninferior to UFH or enoxaparin \u00b1 provisional GPI for the ischemic events while major bleeding significantly lower (3.0% vs 5.7%; RR, 0.53; 95% CI, 0.43 to 0.65; p\u0026lt;0.001). In ISAR-REACT 4, [Kastrati A et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2011] patients with NSTE-ACS treated with PCI were randomized to bivalirudin or UFH plus abciximab. Bivalirudin was noninferior for the endpoint of death, recurrent MI or urgent target vessel revascularization (13.4% vs 12.8%; RR, 0.96; 95% CI, 0.74 to 1.25; p=0.76) and had lower rates of major bleeding (2.6% vs 4.6%; RR, 1.84; 95% CI, 1.10 to 3.07; p=0.02).\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EProf. Valgimigli concluded that fondaparinux in medically treated patients and bivalirudin in PCI patients appears to be efficacious while having a favorable safety profile in terms of bleeding.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECHOOSING THE RIGHT ANTIPLATELET AGENT\u003C\/h2\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe current antiplatelet agents available for P2Y\u003Csub\u003E12\u003C\/sub\u003E inhibition in patients with NSTE-ACS are clopidogrel, prasugrel, and ticagrelor. Strategies to select the optimal agent were discussed by Matthew J. Price, MD, Scripps Clinic, La Jolla, California, USA.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003E\n            \u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E summarizes major trials evaluating antiplatelet agents in patients with ACS. These studies demonstrate the efficacy of prasugrel and ticagrelor compared with clopidogrel, although these agents also were associated with higher bleeding rates.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15879\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15879\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15879\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-12\u0022 class=\u0022first-child\u0022\u003EAntiplatelet Studies in NSTE-ACS\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EDr. Price concluded that treatment for NSTE-ACS should be individualized according to ischemic and bleeding risk. Prasugrel or ticagrelor are preferred when markers of ischemic risk are present, including positive troponin or elevated biomarkers correlated with higher absolute event rates. For noninvasively managed patients, ticagrelor is superior to clopidogrel. Clopidogrel should be used when bleeding risk is high, particularly when concomitant oral anticoagulation is indicated or contraindications are present.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ENOVEL ANTICOAGULATION TARGETS AND AGENTS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EAccording to John H. Alexander, MD, MHS, Duke Clinical Research Institute, Durham, North Carolina, USA, available anticoagulants are effective for NSTE-ACS, but there is room for improvement both for control of ischemic events and for bleeding complications.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EOtamixaban is a specific, direct Factor Xa inhibitor that was studied in moderate- to high-risk NSTE-ACS with planned early invasive management [Steg PG et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2013]. Compared to UFH plus eptifibatide, otamixaban did not improve rates of death or MI (5.5% vs 5.7%; RR, 0.99; 95% CI, 0.85 to 1.16; p=0.93) and increased major bleeding (3.1% vs 1.5%; RR, 2.13; 95% CI, 1.63 to 2.78; p\u0026lt;0.001).\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EREG1 is a two-component, actively controllable anticoagulant system consisting of the Factor IX inhibitor, pegnivacogin and the control agent, anivamerson, which has a specific affinity for pegnivacogin. The RADAR trial [Povsic TJ et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2013] evaluated REG1 versus heparin in NSTE-ACS patients undergoing femoral catheterization. At 30 days, ACUITY bleeding had occurred in 65.0%, 33.6%, 34.5%, 30.4%, and 31.3% of patients with 25%, 50%, 75%, and 100% reversal and heparin, respectively (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). At least 50% pegnivacogin reversal was needed to prevent bleeding. There were numerically but not statistically fewer ischemic events with REG1 versus heparin (3.0% vs. 5.7%, p=0.1). A Phase 3 trial comparing REG1 with bivalirudin, REGULATE-PCI, is ongoing [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01848106\u0026amp;atom=%2Fspmdc%2F14%2F4%2F37.atom\u0022\u003ENCT01848106\u003C\/a\u003E].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/4\/37\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022RADAR: ACUITY Bleeding Through 30 Days\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-2128097965\u0022 data-figure-caption=\u0022RADAR: ACUITY Bleeding Through 30 Days\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/4\/37\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/4\/37\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/4\/37\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15876\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-18\u0022 class=\u0022first-child\u0022\u003ERADAR: ACUITY Bleeding Through 30 Days\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EREG1=pegnivacogin plus control agent, anivamerson.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Povsic TJ et al. A Phase 2, randomized, partially blinded, active-controlled study assessing the efficacy and safety of variable anticoagulation reversal using the REG1 system in patients with acute coronary syndromes: results of the RADAR trial. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2013;34(31)248\u20132489. With permission from Oxford University Press.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EPost-ACS, a number of new oral anticoagulants (NOACs) have been studied. A meta-analysis of the NOACs, ximeligatran, apixaban, rivaroxaban, dabigatran, and darexaban added to single or dual antiplatelet therapy (DAPT) for post-ACS therapy, reported only modest reductions in cardiovascular events and substantial increases in bleeding [Oldgren J et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2013]. Included studies included a variety of agents as well as intensities of anticoagulation.\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EDr. Alexander concluded that available anticoagulants are effective for acute management of NSTE-ACS but challenges remain with ischemic events and bleeding. For post-acute management of NSTE-ACS, adding an anticoagulant at therapeutic doses to current antiplatelet may reduce ischemic events and but increases bleeding. Future studies exploring different doses and new combinations of antiplatelet and anticoagulant agents will define the role of anticoagulation in post-ACS treatment.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ELONG-TERM ANTICOAGULATION THERAPY\u003C\/h2\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EFreek W.A. Verheugt, MD, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands, explored the use of novel anticoagulants for long-term therapy and described the potential for eliminating aspirin or warfarin. Results of a nationwide cohort study in Denmark are shown in \u003Ca id=\u0022xref-table-wrap-3-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T3\u0022\u003ETable 3\u003C\/a\u003E [Lamberts M et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cdiv id=\u0022T3\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15881\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15881\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15881\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 3.\u003C\/span\u003E \n               \u003Cp id=\u0022p-22\u0022 class=\u0022first-child\u0022\u003EBleeding and Ischemic Events\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-23\u0022\u003EThe ASPECT-2 [van Es RF et al. \u003Cem\u003ELancet\u003C\/em\u003E 2002] and WARIS-II [Hurlen M et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2002] studies reported that warfarin alone or combined with aspirin was more effective for preventing ischemic events after MI than aspirin alone but was associated with increased bleeding. In the WOEST trial [Dewilde WJM et al. \u003Cem\u003ELancet\u003C\/em\u003E 2013], patients treated with OAC plus clopidogrel and ASA versus OAC plus clopidogrel had significantly increased bleeding (44.4% vs 19.4%; HR, 0.36; 95% CI, 0.26 to 0.50; p\u0026lt;0.0001) and all-cause mortality (6.3% vs 2.5%; HR, 0.39; 95% CI, 0.16 to 0.93; p=0.027). Ischemic events were not increased by dropping ASA. Another recent study found that OAC plus clopidogrel was equal to or better than triple therapy with respect to ischemic events and bleeding rates [Lamberts M et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cp id=\u0022p-24\u0022\u003EIn the RE-LY study [Dans AL et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2013], patients receiving DAPT plus warfarin or dabigatran (110 or 150 mg) had the highest major bleeding rates compared with those receiving single or no antiplatelet therapy, with the lowest absolute risk among patients on dabigatran 110 mg.\u003C\/p\u003E\n         \u003Cp id=\u0022p-25\u0022\u003EThe evidence shows that in patients requiring oral anticoagulation, DAPT reduces recurrent ischemic events after stenting for ACS but increases bleeding significantly. The use of safer OACs may reduce bleeding in this situation. Omitting ASA and treating with an anticoagulant and clopidogrel after stenting in atrial fibrillation patients seems promising but needs to be confirmed in future trials.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/4\/37.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzpc6p\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzpc6p\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzpc6p\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}