Bridging the Gap in Thrombosis Management: A thread

🧵 1) Welcome to our #accredited #Tweetorial on optimizing thrombosis prevention and antithrombotic care in ACS, AF, and stroke prevention, part of our cardiovascular risk management series. Earn 0.25 CME credits with CCI and MedAll. #Thrombosis #CME

2) Click here to read the accreditation and disclosures information before beginning this activity 👉

Supported by an independent educational grant from Bristol Myers Squibb and Johnson and Johnson. Delivered in joint providership by MedAll & CCI.

So… How confident are you in balancing stroke prevention vs bleeding risk and integrating new data into practice? 🤔Stay tuned 👇

3. Every stroke prevented starts with accurate risk identification: use the CHA₂DS₂-VASc to identify patients at high ischemic risk; use the HAS-BLED to identify modifiable risk factors for bleeding.

🎥 Watch Dr Patel explain how CHA₂DS₂-VASc guides anticoagulation decisions in major AF guidelines.👇

4. The next era of AF care goes beyond CHA₂DS₂-VASc.
   🧬 Biomarkers (NT-proBNP, Troponin-T, BMP-10)
   🫀 Echo measures (LA strain, velocity)
   ⌛ AF burden & duration

🎥 Watch Dr Patel explain how biomarkers and echo measures are enhancing risk stratification and guideline integration.👇

5. Post-ACS, risk doesn’t stop at discharge:

🩸 Procedural/stent events (first 30 days)
🧠 Recurrent MI & stroke (months to years)
🔥 Persistent inflammation & thrombin generation sustain long-term risk.

Reassess antithrombotic intensity regularly to match evolving risk.

6. Many AF patients go undertreated.

When treated, underdosing is frequent, especially in older adults & non-cardiology.

🔹51% of CHA₂DS₂-VASc≥2 never receive anticoagulants.
🔹Underdosing ≠ safer care; it increases stroke risk without reducing bleeding.

Follow evidence, not instinct.

7. DOAC dosing hinges on renal function & weight:

💧
CrCl <15 → avoid all DOACs, except apixaban
CrCl 15–30 → avoid dabigatran
CrCl >95 → avoid edoxaban

⚖️
<60 kg → avoid dabigatran/rivaroxaban/betrixaban

120 kg → avoid dabigatran/edoxaban/betrixaban

Tailor to physiology, not routine.

8. DOAC dosing hinges on renal function & weight:

CrCl<15→only consider apixaban; <30→avoid dabigatran; >95→avoid edoxaban.
<60kg→avoid dabigatran/rivaroxaban/betrixaban; >120kg→avoid dabigatran/edoxaban/betrixaban.

🎥 Watch Dr Rymer explain renal function & weight guiding dosing.

9. DOACs can’t work if not taken.

💬 90% mild nonadherence = forgetfulness
💰 Cost, fear of bleeding, or “no symptoms” drive poor adherence.

Structured conversations raise clarity from 77% → 89%.

Multiple SDM tools (including those at ACC/AHA guidelines), support patient education.

10. ARC post-ACS criteria:

🧓 Age ≥75, renal/liver disease
🩸 Anemia or low platelets
🧠 ICH, stroke, or bleeding diathesis
💊 NSAIDs/steroids or recent surgery

🎥 Watch Dr Patel discuss balancing ischemic & bleeding risk in AF patients needing anticoagulant & antiplatelet therapy.

11. Post-ACS therapy:
    ✅ Default: DAPT ≥12 mo (ticagrelor or prasugrel)
    ⚖️ Bleeding risk ↑: shorter DAPT (1–3 mo), transition to dual therapy if AF (SAPT/OAC combos)
    🩸 High risk: consider P2Y12i monotherapy (ticag) after 1 mo

12. Duration depends on risk — not habit.

Traditional OACs inhibit thrombin or factor Xa, reducing thrombosis but impairing hemostasis.
FXI inhibitors act upstream in the intrinsic pathway, offering a potential way to uncouple thrombosis from hemostasis, a new mechanistic approach to thrombosis prevention & management.

13. Clinical studies of FXI inhibition to date have investigated their role in VTE, AF, stroke, and MI (e.g., PACIFIC-AF, AXIOMATIC-SSP, PACIFIC-STROKE, AZALEA-TIMI 71), with phase 3 trials ongoing in abelacimab, asundexian and milvexian.

14. FXI/FXIa inhibitors may reshape thrombosis prevention through a targeted, evidence-driven approach.

If ongoing trials confirm efficacy and safety, these agents could extend anticoagulation to broader, high-risk populations.

Precision and personalization will define the next era of care.

15. Thrombosis prevention isn’t a single decision, it’s a continuum.

🧠 Identify risk early
💊 Personalize and persist with therapy
🔬 Stay alert to new options like FXI inhibitors

Which challenge do you face most in practice: dosing, bleeding fear, or adherence? Tell us below.

16. Thank you for joining this #accredited #Tweetorial on optimizing antithrombotic therapy in ACS, AF, and stroke prevention.

🧾 Claim your 0.25 CME credit ➡️ https://forms.gle/W3M4XfvFrTKo1YSR7

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