| . | Patients on SAPT . | Patients on DAPT . | Patients on long-term OAC . | Patients on OAC for recentb thromboembolic event . | |
|---|---|---|---|---|---|
| SIC score = 2 | |||||
| Platelet count 100–149 × 109/L or PT ratio 1.2–1.4 | No change | <3 m after PCI or ACS: no change 3–6 m after PCI/ACS: a P2Y12 inhibitor or ASA ≥6 m after PCI/ACS: ASA or a P2Y12 inhibitor | No change | No change | |
| SIC score = 3 | |||||
| Plateleat count 100–149 × 109/L and PT ratio 1.2–1.4 | Platelet count ≥20 × 109/L: no change | <3 m after PCI or ACS: no change or consider P2Y12 inhibitor or ASA | Platelet count 100–149 × 109/L and PT ratio 1.2–1.4: no change | Platelet count 100–149 × 109/L and PT ratio 1.2–1.4: no change | |
| or Platelet count <100 × 109/L or PT ratio >1.4 | Platelet count <20 × 109/L: stop SAPT | Consider ASA if platelet count <20 × 109/L 3–6 m after PCI/ACS: P2Y12 inhibitor or ASA Consider ASA if platelet count <20 × 109/L ≥6 m after PCI/ACS: ASA or clopidogrel Consider no SAPT if platelet count <20 × 109/L | Platelet count <100 × 109/L Change VKA/DOAC to heparinc at prophylactic or intermediate dose | Platelet count 50–100 × 109/L Change VKA/DOAC to therapeutic dosed heparinc, split into two daily doses | |
| SIC score = 5 | |||||
| Platelet count <100 × 109/L and PT ratio >1.4 | Platelet count ≥20 × 109/L: no change Platelet count <20 × 109/L: stop SAPT | <1 m after PCI or ACS: no change if platelet count ≥20 × 109/L or consider P2Y12 inhibitor (clopidogrel) or ASA Consider SAPT-ASA monotherapy if platelets <20 × 109/L 1–3 m after PCI/ACS: P2Y12 inhibitor (clopidogrel) or ASA Consider SAPT–ASA monotherapy if platelets <20 × 109/L ≥3 m after PCI/ACS: ASA or clopidogrel Consider no APT if platelet count <20 × 109/L | Platelet count ≥30 × 109/L: no change Platelet count <30 × 109/L: stop heparinc | Platelet count ≥30 × 109/L: no change Platelet count 30–50 × 109/L: prophylactic dose heparinc Platelet count <30 × 109/L: stop heparinc | |
| . | Patients on SAPT . | Patients on DAPT . | Patients on long-term OAC . | Patients on OAC for recentb thromboembolic event . | |
|---|---|---|---|---|---|
| SIC score = 2 | |||||
| Platelet count 100–149 × 109/L or PT ratio 1.2–1.4 | No change | <3 m after PCI or ACS: no change 3–6 m after PCI/ACS: a P2Y12 inhibitor or ASA ≥6 m after PCI/ACS: ASA or a P2Y12 inhibitor | No change | No change | |
| SIC score = 3 | |||||
| Plateleat count 100–149 × 109/L and PT ratio 1.2–1.4 | Platelet count ≥20 × 109/L: no change | <3 m after PCI or ACS: no change or consider P2Y12 inhibitor or ASA | Platelet count 100–149 × 109/L and PT ratio 1.2–1.4: no change | Platelet count 100–149 × 109/L and PT ratio 1.2–1.4: no change | |
| or Platelet count <100 × 109/L or PT ratio >1.4 | Platelet count <20 × 109/L: stop SAPT | Consider ASA if platelet count <20 × 109/L 3–6 m after PCI/ACS: P2Y12 inhibitor or ASA Consider ASA if platelet count <20 × 109/L ≥6 m after PCI/ACS: ASA or clopidogrel Consider no SAPT if platelet count <20 × 109/L | Platelet count <100 × 109/L Change VKA/DOAC to heparinc at prophylactic or intermediate dose | Platelet count 50–100 × 109/L Change VKA/DOAC to therapeutic dosed heparinc, split into two daily doses | |
| SIC score = 5 | |||||
| Platelet count <100 × 109/L and PT ratio >1.4 | Platelet count ≥20 × 109/L: no change Platelet count <20 × 109/L: stop SAPT | <1 m after PCI or ACS: no change if platelet count ≥20 × 109/L or consider P2Y12 inhibitor (clopidogrel) or ASA Consider SAPT-ASA monotherapy if platelets <20 × 109/L 1–3 m after PCI/ACS: P2Y12 inhibitor (clopidogrel) or ASA Consider SAPT–ASA monotherapy if platelets <20 × 109/L ≥3 m after PCI/ACS: ASA or clopidogrel Consider no APT if platelet count <20 × 109/L | Platelet count ≥30 × 109/L: no change Platelet count <30 × 109/L: stop heparinc | Platelet count ≥30 × 109/L: no change Platelet count 30–50 × 109/L: prophylactic dose heparinc Platelet count <30 × 109/L: stop heparinc | |
These treatment proposals should be considered in light of individual patient characteristics and may not be appropriate if the risk of life-threatening stent thrombosis is high or other patient characteristics suggest that bleeding risk of DAPT or a more effective P2Y12 inhibitor (ticagrelor or prasugrel) outweighs the thrombotic risk.
ACS, acute coronary syndrome; APT, antiplatelet therapy; DAPT, dual antiplatelet therapy; OAC, oral anticoagulant; PT, prothrombin time; SAPT, single antiplatelet therapy; VKA, vitamin K antagonist.
SIC and SOFA definitions and scores are shown in Table 1 and Supplementary data online, Table S3, respectively.
Recent thromboembolism refers to an event within the previous 3 months.
Heparins: low-molecular weight heparin (LMWH) at indicated dose for creatinine clearance >30 mL/min, with dose adjustment for creatinine clearance 15–30 mL/min; unfractionated heparin (UFH) if creatinine clearance <15 mL/min.
Therapeutic dose LMWH should be reduced when the calculated creatinine clearance is <30–40 mL/min according to product monograph, or changed to UFH. If creatinine clearance <15 mL/min, use only UFH.
| . | Patients on SAPT . | Patients on DAPT . | Patients on long-term OAC . | Patients on OAC for recentb thromboembolic event . | |
|---|---|---|---|---|---|
| SIC score = 2 | |||||
| Platelet count 100–149 × 109/L or PT ratio 1.2–1.4 | No change | <3 m after PCI or ACS: no change 3–6 m after PCI/ACS: a P2Y12 inhibitor or ASA ≥6 m after PCI/ACS: ASA or a P2Y12 inhibitor | No change | No change | |
| SIC score = 3 | |||||
| Plateleat count 100–149 × 109/L and PT ratio 1.2–1.4 | Platelet count ≥20 × 109/L: no change | <3 m after PCI or ACS: no change or consider P2Y12 inhibitor or ASA | Platelet count 100–149 × 109/L and PT ratio 1.2–1.4: no change | Platelet count 100–149 × 109/L and PT ratio 1.2–1.4: no change | |
| or Platelet count <100 × 109/L or PT ratio >1.4 | Platelet count <20 × 109/L: stop SAPT | Consider ASA if platelet count <20 × 109/L 3–6 m after PCI/ACS: P2Y12 inhibitor or ASA Consider ASA if platelet count <20 × 109/L ≥6 m after PCI/ACS: ASA or clopidogrel Consider no SAPT if platelet count <20 × 109/L | Platelet count <100 × 109/L Change VKA/DOAC to heparinc at prophylactic or intermediate dose | Platelet count 50–100 × 109/L Change VKA/DOAC to therapeutic dosed heparinc, split into two daily doses | |
| SIC score = 5 | |||||
| Platelet count <100 × 109/L and PT ratio >1.4 | Platelet count ≥20 × 109/L: no change Platelet count <20 × 109/L: stop SAPT | <1 m after PCI or ACS: no change if platelet count ≥20 × 109/L or consider P2Y12 inhibitor (clopidogrel) or ASA Consider SAPT-ASA monotherapy if platelets <20 × 109/L 1–3 m after PCI/ACS: P2Y12 inhibitor (clopidogrel) or ASA Consider SAPT–ASA monotherapy if platelets <20 × 109/L ≥3 m after PCI/ACS: ASA or clopidogrel Consider no APT if platelet count <20 × 109/L | Platelet count ≥30 × 109/L: no change Platelet count <30 × 109/L: stop heparinc | Platelet count ≥30 × 109/L: no change Platelet count 30–50 × 109/L: prophylactic dose heparinc Platelet count <30 × 109/L: stop heparinc | |
| . | Patients on SAPT . | Patients on DAPT . | Patients on long-term OAC . | Patients on OAC for recentb thromboembolic event . | |
|---|---|---|---|---|---|
| SIC score = 2 | |||||
| Platelet count 100–149 × 109/L or PT ratio 1.2–1.4 | No change | <3 m after PCI or ACS: no change 3–6 m after PCI/ACS: a P2Y12 inhibitor or ASA ≥6 m after PCI/ACS: ASA or a P2Y12 inhibitor | No change | No change | |
| SIC score = 3 | |||||
| Plateleat count 100–149 × 109/L and PT ratio 1.2–1.4 | Platelet count ≥20 × 109/L: no change | <3 m after PCI or ACS: no change or consider P2Y12 inhibitor or ASA | Platelet count 100–149 × 109/L and PT ratio 1.2–1.4: no change | Platelet count 100–149 × 109/L and PT ratio 1.2–1.4: no change | |
| or Platelet count <100 × 109/L or PT ratio >1.4 | Platelet count <20 × 109/L: stop SAPT | Consider ASA if platelet count <20 × 109/L 3–6 m after PCI/ACS: P2Y12 inhibitor or ASA Consider ASA if platelet count <20 × 109/L ≥6 m after PCI/ACS: ASA or clopidogrel Consider no SAPT if platelet count <20 × 109/L | Platelet count <100 × 109/L Change VKA/DOAC to heparinc at prophylactic or intermediate dose | Platelet count 50–100 × 109/L Change VKA/DOAC to therapeutic dosed heparinc, split into two daily doses | |
| SIC score = 5 | |||||
| Platelet count <100 × 109/L and PT ratio >1.4 | Platelet count ≥20 × 109/L: no change Platelet count <20 × 109/L: stop SAPT | <1 m after PCI or ACS: no change if platelet count ≥20 × 109/L or consider P2Y12 inhibitor (clopidogrel) or ASA Consider SAPT-ASA monotherapy if platelets <20 × 109/L 1–3 m after PCI/ACS: P2Y12 inhibitor (clopidogrel) or ASA Consider SAPT–ASA monotherapy if platelets <20 × 109/L ≥3 m after PCI/ACS: ASA or clopidogrel Consider no APT if platelet count <20 × 109/L | Platelet count ≥30 × 109/L: no change Platelet count <30 × 109/L: stop heparinc | Platelet count ≥30 × 109/L: no change Platelet count 30–50 × 109/L: prophylactic dose heparinc Platelet count <30 × 109/L: stop heparinc | |
These treatment proposals should be considered in light of individual patient characteristics and may not be appropriate if the risk of life-threatening stent thrombosis is high or other patient characteristics suggest that bleeding risk of DAPT or a more effective P2Y12 inhibitor (ticagrelor or prasugrel) outweighs the thrombotic risk.
ACS, acute coronary syndrome; APT, antiplatelet therapy; DAPT, dual antiplatelet therapy; OAC, oral anticoagulant; PT, prothrombin time; SAPT, single antiplatelet therapy; VKA, vitamin K antagonist.
SIC and SOFA definitions and scores are shown in Table 1 and Supplementary data online, Table S3, respectively.
Recent thromboembolism refers to an event within the previous 3 months.
Heparins: low-molecular weight heparin (LMWH) at indicated dose for creatinine clearance >30 mL/min, with dose adjustment for creatinine clearance 15–30 mL/min; unfractionated heparin (UFH) if creatinine clearance <15 mL/min.
Therapeutic dose LMWH should be reduced when the calculated creatinine clearance is <30–40 mL/min according to product monograph, or changed to UFH. If creatinine clearance <15 mL/min, use only UFH.
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