ABC | Volume 113, Nº1, July 2019

Statement Statement on Antiplatelet Agents and Anticoagulants in Cardiology – 2019 Arq Bras Cardiol. 2019; 113(1):111-134 Content 1. Introduction .....................................................................................113 2. Antithrombotic Therapy in Patients Using Oral Anticoagulants and Undergoing Percutaneous Coronary Intervention .......................................................................113 2.1. Introduction ........................................................................................113 2.2. Management of Antithrombotic Agents and the Moment of Percutaneous Coronary Intervention ..........................................................114 2.3. Choosing Stent Type for Percutaneous Coronary Intervention .............115 2.4. Long-term Antithrombotic Therapy following Percutaneous Coronary Intervention ................................................................................115 3. Duration Of Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention ..........................................116 3.1. Introduction ........................................................................................116 3.2. Risk Scores .........................................................................................117 3.3. Dual Antiplatelet Therapy Duration following Percutaneous Coronary Intervention for Stable Coronary Artery Disease ..........................119 3.4. Dual Antiplatelet Therapy Duration following Percutaneous Coronary Intervention for Acute Coronary Artery Disease ...........................119 4. Reversal of New Anticoagulants .............................................120 4.1. Introduction ........................................................................................120 4.2. Antidotes ............................................................................................120 4.3. Idarucizumab ......................................................................................121 4.3.1. Andexanet Alfa ................................................................................121 4.4. Alternative Therapies ..........................................................................121 5. Pericardioversion Anticoagulation in Atrial Fibrillation .............................................................................................122 5.1. Introduction ........................................................................................122 5.2. Strategies for Pericardioversion Anticoagulation in Atrial Fibrillation .................................................................................................122 6. Anticoagulation and Antiplatelet Therapy in Patients with Patent Foramen Ovale ..........................................124 6.1. Introduction ........................................................................................124 6.2. Relation between Patent Foramen Ovale and Cryptogenic Stroke ........................................................................................................124 6.3. Evidence for the Use of Antiplatelet Agents or Anticoagulants in Patients with Patent Foramen Ovale ......................................................125 7. Antithrombotic Therapy in Oncology Patients with Thrombocytopenia .................................................................127 7.1. Introduction ........................................................................................127 7.2. Antithrombotic Therapy .......................................................................127 References ...........................................................................................127 1. Introduction In 2013, the Brazilian Cardiology Society published the “Brazilian Guidelines on Antiplatelet and Anticoagulant Agents in Cardiology.” Over the past years, new studies have been carried out, providing important information on the use of these medications, administered alone and in combination with other medications. It is, therefore, time to review our guidelines and update them with this new knowledge which has been produced. We have carried out an extensive review of the literature, and for this update we have chosen to emphasize 6 major topics in clinical practice which have undergone innovation over the past years or which were not covered in the previous document. The themes of this update are: 1. Antithrombotic therapy in patients using oral anticoagulants and undergoing percutaneous coronary intervention (PCI); 2. Duration of dual antiplatelet therapy following PCI; 3. Reversal of new anticoagulants; 4. Pericardioversion anticoagulation in atrial fibrillation (AF); 5. Anticoagulation and antiplatelet therapy in patients with patent foramen ovale; 6. Antithrombotic therapy in oncology patients with thrombocytopenia. In this update, grade of recommendations and level of evidence were applied in accordance with the following standards. It is our hope that this document may be of benefit to all professionals who, in their daily practice, face dilemmas and doubts regarding the best manner to prescribe various options and doses of available anticoagulants and antiplatelet agents. Grade of recommendation Grade I Conditions for which there is conclusive evidence or, in the absence of conclusive evidence, general consensus that the procedure is safe and useful/effective Grade IIa Conditions for which there are conflicting evidence and/ or divergent opinions regarding the procedure’s safety and usefulness/effectiveness. Weight or evidence/opinion in favor of the procedure. The majority of studies/experts approve. Grade IIb Conditions for which there are conflicting evidence and/ or divergent opinions regarding the procedure’s safety and usefulness/effectiveness. Safety and usefulness/effectiveness less well established, with no prevailing opinions in favor. Grade III Conditions for which there is evidence and/or consensus that the procedure is not useful/effective and may, in some cases, be potentially harmful Level of evidence Level A Data obtained from multiple concordant large randomized trials and/ or robust meta-analysis of randomized clinical trials Level B Data obtained from less robust meta-analysis, from a single randomized trial, or from non-randomized (observational) trials Level C Data obtained through consensus of expert opinion 2. Antithrombotic Therapy in Patients Using Oral Anticoagulants and Undergoing Percutaneous Coronary Intervention 2.1. Introduction Approximately 6% to 8% of patients undergoing PCI have a concomitant indication for long-term oral anticoagulant use, owing to various reasons such as AF, mechanical valves, or thromboembolism. 1-4 It is, thus, fundamental to define the best way to treat these patients, especially regarding the combination of antiplatelet and anticoagulant medications. 113