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Antiplatelettreatment
LastrevisedinOctober2015

Changes

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LastrevisedinOctober2015
October2015minorupdate.BasedonanupdatetotheSummaryofProductCharacteristicsforPlavix(clopidogrel),thelistofCYP2C19inhibitors
thatmayinteractwithclopidogrelhasbeenamendedsothatitnowlistsstrongormoderateCYP2C19inhibitors(ciprofloxacin,cimetidine,
oxcarbazepine,andchloramphenicolhavebeenremoved)[ABPIMedicinesCompendium,2015(/antiplatelettreatment#!references/376978)].
May2015minorupdate.Gynaecomastiahasbeenaddedasarareadverseeffectofclopidogrel[ABPIMedicinesCompendium,2015(/antiplatelet
treatment#!references/376978)].
January2014minorupdate.MinorupdatetothetexttoreflectrecentlypublishedadvicefromtheMedicinesandHealthcareproductsRegulatory
Agency(MHRA)regardingtherarebutseriousadverseeffectofacquiredhaemophiliaassociatedwithclopidogrel[MHRA,2013(/antiplatelet
treatment#!references/376978)].
August2013reviewed.AliteraturesearchwasconductedinAugust2013toidentifyevidencebasedguidelines,UKpolicy,systematicreviews,and
keyRCTspublishedsincethelastrevisionofthetopic.Thestructureofthistopichasbeenchangedtoimproveclarityandtherearesomechangestothe
recommendations.Prescribinginformationonprasugrelandticagrelorisnowincluded,andclopidogrel(insteadofaspirinanddipyridamole)isnow
recommendedasthepreferredantiplateletforuseafteratransientischaemicattack.

Previouschanges

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June2013minorupdate.The2013QOFoptionsforlocalimplementationhavebeenaddedtothistopic[BMAandNHSEmployers,2013
(/antiplatelettreatment#!references/376978)].
October2012minorupdate.The2012QIPPoptionsforlocalimplementationhavebeenaddedtothistopic[NPC,2012(/antiplatelet
treatment#!references/376978)].
March2012minorupdate.The2012/2013QOFindicatorshavebeenaddedtothistopic[BMAandNHSEmployers,2012(/antiplatelet
treatment#!references/376978)].IssuedinApril2012.
May2011minorupdate.TheMedicinesandHealthcareproductsRegulatoryAgency(MHRA)hasissueddrugsafetyadviceregardingtherare
associationofprasugrelwithreportsofserioushypersensitivityreactions[MHRA,2011(/antiplatelettreatment#!references/376978)].Inadditionthe
2011/2012QOFindicatorsandthe2010/2011QIPPoptionsforlocalimplementationhavebeenaddedtothistopic[BMAandNHSEmployers,2011
(/antiplatelettreatment#!references/376978)NPC,2011(/antiplatelettreatment#!references/376978)].IssuedinJune2011.
February2011topicstructurerevisedtoensureconsistencyacrossCKStopicsnochangestoclinicalrecommendationshavebeenmade.
February2011updated.ThenewrecommendationsfromNICEtechnologyappraisal210Clopidogrelandmodifiedreleasedipyridamoleforthe
preventionofocclusivevasculareventshavebeenincorporatedintothistopic[NICE,2010c(/antiplatelettreatment#!references/376978)].Issuedin
February2011.
December2010minorupdatetotheSupportingevidencesectiononAdverseeffectsofaspirinandclopidogrel.IssuedinDecember2010.
September2010minorupdate.Anewmetaanalysisevaluatingaspirinforprimarypreventionofcardiovasculardiseaseinpeoplewithdiabeteshas
beenaddedtotheSupportingevidence(/antiplatelettreatment#!supportingevidence)section.IssuedinSeptember2010.
April2010minorupdate.TheMedicinesandHealthcareproductsRegulatoryAgency(MHRA)hasissuedrevisedadviceregardingtheinteraction
betweenclopidogrelandprotonpumpinhibitors.Omeprazoleandesomeprazoleshouldnotbeusedwithclopidogrel.However,thecurrentevidence
doesnotsupportextendingthisadvicetootherPPIs[MHRA,2010(/antiplatelettreatment#!references/376978)].AdvicefromSIGNthataspirinisno
longerrecommendedforprimarypreventionofcardiovasculardiseaseinpeoplewithdiabeteshasalsobeenadded[SIGN,2010(/antiplatelet
treatment#!references/376978)].IssuedinApril2010.

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December2009minorupdate.AdviceaboutvenlafaxineinpeopletakinglowdoseaspirinhasbeenaddedtothesectiononDruginteractions

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December2009minorupdate.AdviceaboutvenlafaxineinpeopletakinglowdoseaspirinhasbeenaddedtothesectiononDruginteractions

(/topicunderreview)forlowdoseaspirin.TheSupportingevidencesectiononantiplatelettreatmentforprimarypreventionofcardiovasculardisease,
andtherecommendationsonwhentoconsiderantiplatelettreatmentforprimarypreventionofcardiovasculardiseasehavealsobeenupdated.Issuedin
December2009.
November2009minorupdate.OtherinhibitorsofCYP219CaddedtothesectiononDruginteractions(/topicunderreview)forclopidogrel.Advice
aboutchoiceofantidepressantinpeopletakinglowdoseaspirinhasbeenaddedtothesectiononDruginteractions(/topicunderreview)forlowdose
aspirin.IssuedinNovember2009.
October2009minorupdate.Typographicalerrorcorrected.AreminderfromtheMHRA[MHRA,2009c(/antiplatelettreatment#!references/376978)]
thataspirinisnotlicensedforuseinprimarypreventionofvasculareventshasalsobeenadded.IssuedinOctober2009.
September2009minorupdate.TheMHRAadvisesthatcimetidineandclopidogrelshouldnotbecoprescribedbecausecimetidineinhibitsthe
CytochromeP450enzymeCYP2C19.IssuedinSeptember2009.
FebruarytoJuly2009convertedfromCKSguidancetoCKStopicstructure.Theevidencebasehasbeenreviewedindetail,and
recommendationsaremoreclearlyjustifiedandtransparentlylinkedtothesupportingevidence.
Therehavebeennomajorchangestotherecommendations.
June2009minorupdate.Typographicalerrorcorrected.IssuedinJune2009.
April2009minorupdate.TheGMSqualityindicatorssectioninGoalsandoutcomemeasureshasbeenrenamedQOFindicators.IssuedinMay
2009.
January2009minortypographicalcorrectionsmadetoSupportingevidencesection.IssuedinFebruary2009.
October2008minorupdatetotheSupportingevidencesectiononstrategiestoreduceriskofaspirininducedgastrointestinalcomplications,
makingitclearthatprotonpumpinhibitorsforgastroprotectionareallsimilarlyeffectiveatlicenseddoses,andthatstandarddosesofprotonpump
inhibitors(atdoseslicensedforgastroprotection)shouldbeusedwherenecessary.IssuedinNovember2008.
January2008updatedtoincludeinformationonwhattodoifbloodpressurecontroldeterioratesinsomeonetakingaspirinforprimarypreventionof
cardiovasculardisease.IssuedinJanuary2008.
AprilJune2006written.ValidatedinSeptember2006andissuedinOctober2006.

Update

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Newevidence

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Evidencebasedguidelines
Nonewevidencebasedguidelinessince1August2013.
HTAs(HealthTechnologyAssessments)
NonewHTAssince1August2013.
Economicappraisals
NoneweconomicappraisalsrelevanttoEnglandsince1August2013.
Systematicreviewsandmetaanalyses
Systematicreviewspublishedsincethelastrevisionofthistopic:
Zhao,Z.G.,Chen,M.,Peng,Y.,etal.(2014)Theimpactofsmokingonclinicalefficacyanfpharmacodynamiceffectsofclopidogrel:asystematic
reviewandmetaanalysis.Heart100(3),192199.[Abstract(http://lcyyy.ecpedk.lcpno.lcpkj.lciqx.uk2.gsr.awhoer.net/pubmed/23749792)]
Primaryevidence
Nonewrandomizedcontrolledtrialspublishedinthemajorjournalssince1August2013.

Newpolicies

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Nonewnationalpoliciesorguidelinessince1August2013.

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Newsafetyalerts

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Nonewsafetyalertssince1August2013.

Changesinproductavailability

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Clopidogrelratiopharm(clopidogrel)hasjustbeenlaunchedandisforthepreventionofatherothromboticandthromboemboliceventsinadults.
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Goals
Toprescribeappropriateantiplatelettreatmentfortheprimaryandsecondarypreventionofcardiovasculardisease
Toassessandtoreducetheriskofgastrointestinalbleedingassociatedwithantiplatelettreatment
Tomanageantiplateletassociateddyspepsia
Toinitiateantiplatelettreatmentappropriatelyinpeoplewithraisedbloodpressure
Tomanagesomeoneonantiplatelettreatmentwhodevelopsraisedbloodpressure

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QOFindicators

Table1.IndicatorsrelatedtoantiplatelettreatmentintheQualityandOutcomesFramework(QOF)oftheGeneralMedicalServices(GMS)contract.
Indicator

Points Payment
stages

CHD005Thepercentageofpatientswithcoronaryheartdiseasewitharecordinthepreceding12monthsthataspirin,an

5696%

alternativeantiplatelettherapy,orananticoagulantisbeingtaken.
CHD006Thepercentageofpatientswithahistoryofmyocardialinfarction(onorafter1April2011)currentlytreatedwithanACEI 10

60100%

(orARBifACEIintolerant),aspirinoranalternativeantiplatelettherapy,betablockerandstatin.
STIA007Thepercentageofpatientswithastrokeshowntobenonhaemorrhagic,orahistoryofTIA,whohavearecordinthe

5797%

5797%

4090%

preceding12monthsthatanantiplateletagent,orananticoagulantisbeingtaken.
AF003InthosepatientswithatrialfibrillationinwhomthereisarecordofaCHADS2scoreof1(latestinthepreceding12
months),thepercentageofpatientswhoarecurrentlytreatedwithanticoagulationdrugtherapyorantiplatelettherapy.
PAD004Thepercentageofpatientswithperipheralarterialdiseasewitharecordinthepreceding12monthsthataspirinoran
alternativeantiplateletisbeingtaken.
Datafrom:[BMAandNHSEmployers,2013(/antiplatelettreatment#!references/376978)]

Definition

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Whatisantiplatelettreatment?
Antiplatelettreatmentisdrugtreatmentthatpreventstheformationofbloodclots(thrombi)bypreventingplateletaggregation.

Mechanismofaction

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Howdoantiplateletdrugswork?
Damagetothevascularendothelium(forexamplefromcigarettesmoking,diabetesmellitus,orelevatedlowdensitylipoproteincholesterollevels)
resultsinthedevelopmentofatheroscleroticplaques.Ifthesebecomedisrupted,plateletrichthrombiforminthebloodvesselsandcanleadto
occlusionofthebloodvesselordistalembolizationandresultinacutecardiovasculareventssuchasmyocardialinfarctionandstroke.
Activationandaggregationofplateletsisanintegralpartofthrombusformation.Antiplateletdrugsinhibitthrombusformationitisbelievedthatthisis
howtheyexerttheircardiovascularprotectiveeffect.
Fourmaintypesofantiplateletdrugsareavailable:
Aspirinirreversiblyinhibitscyclooxygenaseandblockstheproductionofthromboxane.Itisthemostcommonlyused,andmostextensively
studied,antiplateletdrug[NICEetal,2004(/antiplatelettreatment#!references/376978)].
Clopidogrelprasugrelandticagrelorarethienopyridines.Theyinhibitthebindingofadenosinediphosphatetoitsplateletreceptor,andthisis
thoughttoinhibitplateletaggregationbyblockingactivationoftheglycoproteinIIb/IIIapathway[NICEetal,2004(/antiplatelet
treatment#!references/376978)NICE,2011(/antiplatelettreatment#!references/376978)].
Dipyridamolehasbothantiplateletandvasodilatoryproperties.Itisbelievedtoinhibituptakeofadenosineintoerythrocytes,platelets,and
endothelialcells,resultinginanincreasedextracellularconcentrationofadenosinewhichisapotentinhibitorofplateletactivationandaggregation.
Itmayalsoactbyinhibitingthebreakdownofcyclicguanosinemonophosphate[NICEetal,2004(/antiplatelettreatment#!references/376978)].
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GlycoproteinIIb/IIIainhibitors(abciximab,eptifibatide,andtirofiban)blockthebindingoffibrinogentoglycoproteinIIb/IIIareceptorsonthe

platelet[NICE,2002(/antiplatelettreatment#!references/376978)].TheyaregivenintravenouslyandarenotdiscussedfurtherinthisCKStopicas

platelet[NICE,2002(/antiplatelettreatment#!references/376978)].TheyaregivenintravenouslyandarenotdiscussedfurtherinthisCKStopicas
theycanonlybegiveninhospitaltohighriskpeopleundergoingpercutaneouscoronaryinterventionsortopeoplewithacutecoronarysyndrometo
preventearlymyocardialinfarction.

Indications

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Whataretheindicationsforantiplatelettreatment?
Antiplatelettreatmentsaregivenfor:
Theprimarypreventionofcardiovascularevents,insomepeople,whentheriskisparticularlyhigh.
Thesecondarypreventionofcardiovasculareventsinpeoplewith:
Angina.
Myocardialinfarction.
Strokeandtransientischaemicattack.
Peripheralarterialdisease.
Atrialfibrillationalthoughanticoagulantsareusuallyused.
Thetreatmentofpeoplewithacutecoronarysyndrome.
[BNF65,2013(/antiplatelettreatment#!references/376978)]

Complications

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Whatarethecomplicationsofantiplatelettreatment?
Antiplateletdrugsincreasetheriskofbleeding,whichcanleadtocomplicationssuchasgastrointestinalbleeding.
Theriskisfurtherincreasedwhenantiplateletdrugsareusedincombinationwithoneanotherorwithdrugsknowntoincreasebleeding(forexample
anticoagulants).
[BNF65,2013(/antiplatelettreatment#!references/376978)]

Scenario:PrimarypreventionofCVD

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Scenario:Antiplatelettreatmentforprimarypreventionofcardiovasculardisease(CVD)
Agefrom16yearsonwards

Whentoprescribeantiplatelettreatment(primaryprevention)

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Whenshouldantiplatelettreatmentbeprescribedforprimarypreventionofcardiovasculardisease?
Donotroutinelyprescribeantiplatelettreatmentfortheprimarypreventionofcardiovasculardisease(CVD).
Forpeoplewithhypertension,recommendationsfromguidelinesandexpertopinionvary.
Someexpertsrecommendtreatmentwithaspirinforpeoplewithhypertensionand:
Whoareagedover50yearswithahighCVDrisk(10yearsCVDriskgreaterthan20%),or
Haveareducedrenalfunction(forexampleestimatedGlomerularFiltrationRatelessthan45mL/min/1.73m2).
Indecidingwhethertotreatornottreatwithaspirinconsiderthefollowing:
AspirinisnotlicensedfortheprimarypreventionofCVD.
PeopleinthesegroupsmaybeabletoreducetheirCVDriskthroughothermeanssuchasstoppingsmokingorstartingastatin.Formore
informationseetheCKStopiconCVDriskassessmentandmanagement(/cvdriskassessmentandmanagement).
Evidenceforthebenefitsofaspirinisweakinthesegroupsofpeopleandlimitedtosubgroupanalysis.
Thebalanceofbenefittoharmmodestlyfavourstreatmentwithaspirin.
Ifaspirinisbeingconsidered,discussthelikelybenefits(reducedCVDrisk)andrisks(suchasgastrointestinalbleeding).
Forpeoplewithhighbloodpressure(greaterthan150/90mmHg):
Controlhighbloodpressureassoonaspossible.Forinformationonbloodpressuremanagement,seetheCKStopiconHypertensionnot
diabetic(/hypertensionnotdiabetic).
Donotstartaspirinfortheprimarypreventionofcardiovasculardiseaseuntilbloodpressureislessthan150/90mmHg.
Forpeopleatriskofdevelopingdyspepsiaorwhohavedevelopeddyspepsiaafterstartingtreatment,seePreventingdyspepsia
(/antiplatelettreatment#!scenariorecommendation:3),andManagingantiplateletinduceddyspepsia(/antiplatelet
treatment#!scenariorecommendation:4),inthescenarioSecondarypreventionofCVD(/antiplatelettreatment#!scenario:1).

Basisforrecommendation

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Peoplewhoarenothypertensive
AspirinisnotrecommendedforpeopleatlowCVDriskwhoarenothypertensivebecausethereisgoodqualityevidence(/antiplatelet
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treatment#!supportingevidence1:1)thatthemodestreductioninCVDriskwithlowdoseaspirinisbalancedbyamodestincreaseintheriskof
seriousbleeding.ThisisinlinewithguidelinespublishedbyScottishIntercollegiateGuidelinesNetwork(SIGN)Antithrombotics:indicationsand
management[SIGN,2013(/antiplatelettreatment#!references/376978)]andtheEuropeanCardiologySociety(ESC)Europeanguidelineson

management[SIGN,2013(/antiplatelettreatment#!references/376978)]andtheEuropeanCardiologySociety(ESC)Europeanguidelineson
cardiovasculardiseasepreventioninclinicalpractice[Perketal,2012(/antiplatelettreatment#!references/376978)].
Peoplewithhypertension
AspirinisnotrecommendedforpeoplewithhypertensionatlowCVDriskandnormalrenalfunctionbecausethereisgoodqualityevidence
(/antiplatelettreatment#!supportingevidence1:2)thatthemodestreductioninCVDriskwithlowdoseaspirinisbalancedbyamodestincreaseinthe
riskofseriousbleeding.
ForpeoplewithhypertensionandeitherimpairedrenalfunctionoraraisedCVDriskthereisweakevidence(/antiplatelet
treatment#!supportingevidence1:2/608515)thatthereductioninCVDriskwithlowdoseaspirinoutweighsthemodestriskofseriousbleeding.
Expertopiniondiffersonhowtointerpretthisevidence:
TheBritishHypertensionSociety(BHS)issuedapositionstatementin2010withregardstotheuseofaspirinforprimarypreventionof
cardiovasculardisease[BHS,2010(/antiplatelettreatment#!references/376978)].Thisfollowedthepublicationoftwometaanalysesanda
largerandomizedcontrolledtrialthatquestionedthebenefitsofaspirinforprimaryprevention[AntithromboticTrialists'(ATT)Collaborationetal,
2009(/antiplatelettreatment#!references/376978)DeBerardisetal,2009(/antiplatelettreatment#!references/376978)Fowkesetal,2010
(/antiplatelettreatment#!references/376978)].FollowingtheirreviewofthisevidencetheBHSconcludedthat'untilnewinformationbecomes
availablefromongoingtrials,theBHSWorkingPartyreaffirmsitsearlierrecommendationsthataspirinuseinthepreventionofcardiovascular
diseaseinhypertensivepeopleshouldberestrictedtopatientswithpriorhistoryofcardiovasculardiseaseand,inprimaryprevention,tothose
agedover50yearswith10yearcardiovascularriskofatleast20%.AsadvocatedbyMedicinesandHealthcareproductsRegulatoryAgency
(MHRA),physiciansshouldweighupthebenefitsandrisksoflowdoseaspirininallindividuals.Anaccuratequantitativeassessmentof10year
cardiovascularriskisessentialbeforeprescribingaspirinfortheprimarypreventionofcardiovasculardisease.'Theserecommendationswere
stronglyinfluencedbyasubgroupanalysisoftheHypertensionOptimalTreatment(HOT)trial[Zanchettietal,2002(/antiplatelet
treatment#!references/376978)].
TheEuropeanSocietyofCardiology(ESC)advisetoconsiderprescribingaspirinforprimarypreventioninpeoplewithhypertensionwhohave
reducedrenalfunction,orareathighcardiovascularrisk[Perketal,2012(/antiplatelettreatment#!references/376978)].TheESCbasethis
recommendationontheresultsofthreesubgroupanalysesoftheHOTtrial[Ruilopeetal,2001(/antiplatelettreatment#!references/376978)
Zanchettietal,2002(/antiplatelettreatment#!references/376978)Jardineetal,2010(/antiplatelettreatment#!references/376978)].Weak
evidence(/antiplatelettreatment#!supportingevidence1:2/608515)fromthesethreesubgroupanalysessuggestthataspirinmaybebeneficial
forpeoplewhohavehypertensionandreducedkidneyfunctionorahightoveryhighcardiovascularrisk[Ruilopeetal,2001(/antiplatelet
treatment#!references/376978)Zanchettietal,2002(/antiplatelettreatment#!references/376978)Jardineetal,2010(/antiplatelet
treatment#!references/376978)].Highriskwasdefinedasariskofhavingamajorcardiovasculareventinthenext10yearsof2030%,and
veryhighriskwasdefinedasariskofamajorcardiovasculareventof30%ormoreoverthenext10years.
PublishedguidancefromSIGNonantithromboticsdoesnotspecificallydiscusstheuseofantiplateletsforpeoplewithhypertension,butstates
that'Aspirinisnotrecommendedforprimarypreventionofvasculardiseasewhenbenefitsareconsideredagainsttheincreasedriskof
haemorrhage'[SIGN,2013(/antiplatelettreatment#!references/376978)].SIGNbasethisrecommendationontheabovemetaanalysis
[AntithromboticTrialists'(ATT)Collaborationetal,2009(/antiplatelettreatment#!references/376978)].
Forpeoplewithhypertensionandrenalimpairment,weakevidencefromtwosubgroupanalysesoftheHypertensionOptimalTreatment(HOT)trial
suggeststhataspirinmayhaveamodestbenefit[Ruilopeetal,2001(/antiplatelettreatment#!references/376978)Jardineetal,2010
(/antiplatelettreatment#!references/376978)].Weakstatisticallysignificantdifferencesinfavourofaspirinwereseeninpeoplewithanestimated
glomerularfiltrationrateof45mL/min/1.73m2orless[Jardineetal,2010(/antiplatelettreatment#!references/376978)].
Peoplewithdiabetes
Guidelinespublishedin2008bytheNationalInstituteforHealthandCareExcellence(NICE)Type2diabetes:themanagementoftype2
diabetesrecommendsconsideringanantiplateletdrugforpeoplewithdiabeteswhoare[NICE,2009a(/antiplatelet
treatment#!references/376978)]:
Over50yearsofage.
Lessthan50yearsofagewithothersignificantcardiovascularriskfactorsincludingfeaturesofmetabolicsyndromestrongearlyfamilyhistory
ofcardiovasculardiseasesmokinghypertensionormicroalbuminuria.
Howeverthisrecommendationislargelyextrapolatedfromsubgroupanalysisofrandomizedcontrolledtrials(RCTs)thatinvestigatedthebenefits
ofantiplateletdrugs(mainlyaspirin)inotherpopulationswithageneralizedriskofcardiovasculardisease.Subsequenttothepublicationofthe
NICEguidelinesgoodqualityevidence(/antiplatelettreatment#!supportingevidence1:3/608516)fromthreemetaanalyses(n=10,11711,618
7,374)conductedinpeoplewithdiabetesfoundnoclearbenefitofaspirinintheprimarypreventionofcardiovasculareventsinpeoplewith
diabetes[DeBerardisetal,2009(/antiplatelettreatment#!references/376978)Younisetal,2010(/antiplatelettreatment#!references/376978)
Zhangetal,2010(/antiplatelettreatment#!references/376978)].
AdvicefromSIGNguidelinesontheManagementofdiabetesisthataspirinshouldnotbeusedforprimarypreventioninpeoplewithdiabetes
[SIGN,2010(/antiplatelettreatment#!references/376978)].Thisrecommendationwasbasedontheresultsofthreetrialsandametaanalysis
[Hanssonetal,1998(/antiplatelettreatment#!references/376978)Belchetal,2008(/antiplatelettreatment#!references/376978)Ogawaetal,
2008(/antiplatelettreatment#!references/376978)DeBerardisetal,2009(/antiplatelettreatment#!references/376978)].
TheESCbasetheirrecommendationnottoprescribeaspirinforpeoplewithdiabetesontheresultsofonemetaanalysis[DeBerardisetal,2009
(/antiplatelettreatment#!references/376978)].
Discussingthebenefitsandrisksofantiplatelettreatment
TheMedicinesandHealthcareproductsRegulatoryAgency(MHRA)recommendthatifaspirinisusedforprimaryprevention(offlabeluse),the
balanceofbenefitsandrisksshouldbeconsideredforeachindividual[MHRA,2009c(/antiplatelettreatment#!references/376978)].
Controllingbloodpressurebeforestartinganantiplatelet

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Therecommendationtocontrolbloodpressure(BP)beforestartingantiplatelettreatmentfortheprimarypreventionofcardiovasculardiseaseisin

Therecommendationtocontrolbloodpressure(BP)beforestartingantiplatelettreatmentfortheprimarypreventionofcardiovasculardiseaseisin
linewiththoseissuedbytheJointBritishSocieties[BritishCardiacSocietyetal,2005(/antiplatelettreatment#!references/376978)].Itisbasedon
evidencethatantiplatelettreatmentfortheprimarypreventionofcardiovasculardiseaseislessfavourableinpeoplewithelevatedBPbecausethe
riskbenefitratiobecomesmoreunfavourablegiventhatthebenefitsofaspirinmaybereducedinpeoplewithelevatedBP.
SubgroupanalysisoftheThrombosisPreventionTrial(n=5499menatincreasedriskofcoronaryheartdisease)foundthataspirinreducedtotal
cardiovasculareventsinpeoplewhosesystolicBPonentrytothetrialwaslessthan130mmHg(relativerisk[RR]0.59,p=0.0001)andinthose
withsystolicBPbetween130and145mmHg(RR0.68,p=0.0001),butnotinthosewhosesystolicBPwasgreaterthan145mmHg(RR1.08,
p=0.0001)[MeadeandBrennan,2000(/antiplatelettreatment#!references/376978)].
InthePhysicians'HealthStudy(n=22,071),aspirinwaslesseffectiveatreducingriskofmyocardialinfarctioninpeoplewithsystolicBPgreater
than150mmHgthaninthosewithsystolicBPbetween130and149mmHgorthosewithsystolicBPlessthan130mmHg(0.65,comparedto
0.55,comparedto0.52)[Physicians'HealthStudyResearchGroup,1989(/antiplatelettreatment#!references/376978)Haydenetal,2002
(/antiplatelettreatment#!references/376978)].

Scenario:SecondarypreventionofCVD

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Scenario:Antiplatelettreatmentforsecondarypreventionofcardiovasculardisease(CVD)
Agefrom16yearsonwards

Whentoprescribeantiplatelettreatment

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Whenshouldantiplatelettreatmentbeprescribedforsecondarypreventionofcardiovasculardisease?
Antiplatelettreatmentshouldbeprescribedforthesecondarypreventionofcardiovasculareventsinpeoplewith:
Angina.
Apreviousmyocardialinfarction.
Apreviousstrokeortransientischaemicattack.
Peripheralarterialdisease.
Atrialfibrillationalthoughanticoagulantsarenormallyused.
Forfurtherinformation,seetheCKStopicsonAngina(/angina),MIsecondaryprevention(/misecondaryprevention),Atrialfibrillation(/atrial
fibrillation),andStrokeandTIA(/strokeandtia).

Basisforrecommendation

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TheserecommendationsareinlinewithUKandEuropeanguidelinesontheuseofantiplatelettreatmentforsecondarypreventionofcardiovascular
disease[BritishCardiacSocietyetal,2005(/antiplatelettreatment#!references/376978)NICE,2010b(/antiplatelettreatment#!references/376978)
NICE,2010c(/antiplatelettreatment#!references/376978)IntercollegiateStrokeWorkingParty,2012(/antiplatelettreatment#!references/376978)
Perketal,2012(/antiplatelettreatment#!references/376978)SIGN,2013(/antiplatelettreatment#!references/376978)].

Whichantiplatelettreatment

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WhichantiplatelettreatmentshouldIprescribeforsecondarypreventionofcardiovasculardisease?
Theindicationsforthedifferentantiplateletdrugsare:
Myocardialinfarction:treatlongtermwithlowdoseaspirin(75mgdailyformostpeople).Clopidogrel(75mgdaily)isanalternativeifaspirinis
contraindicated(/antiplatelettreatment#!prescribinginfosub:1)ornottolerated(/antiplatelettreatment#!scenarioclarification).
ForpeoplewithacutecoronarysyndromewithoutSTsegmentelevation:
Followingtheacuteevent,acombinationoflowdoseaspirin(usually75mgdaily)pluseitherclopidogrel75mgdailyorticagrelor90mgtwicea
dayisgivenfor12months.
Lowdoseaspirinisthencontinuedalonelongterm.
ForpeoplewithacutecoronarysyndromewithSTsegmentelevation:
Followingtheacuteevent,acombinationoflowdoseaspirin(usually75mgdaily)pluseitherclopidogrel75mgdailyorticagrelor90mgtwicea
dayisrecommended.
Ifclopidogrelandaspirinwereused,continuetheseforatleast1month.Ifaspirinandticagrelorwereused,continuetheseforupto12months.
Lowdoseaspirinisthencontinuedalonelongterm.
Coronaryorcarotidinterventions,suchasstenting
Ingeneral,lowdoseaspirin(75300mg)incombinationwithoneofthefollowingantiplateletsisinitiatedinsecondarycare:
Clopidogrel75mgdaily,or
Prasugrel10mgdaily(or5mgdailyifthepersonweighslessthan60kg,orifthepersonis75yearsofageorolder),or
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Ticagrelor90mgtwiceaday.
Treatmentisusuallycontinuedforupto12monthsaftertheprocedure(unlessotherwisespecifiedbythespecialist).Afterthestatedperiodof

treatment,antiplatelettreatmentiscontinuedwithlowdoseaspirinalone.
Ischaemicstrokeandtransientischaemicattack