Antithrombotic and Antiplatelet Therapy
Parenteral anticoagulant therapies include heparin and related compounds, as well as the direct thrombin inhibitors argatroban and bivalirudin. Commonly used fibrinolytic therapies include alteplase, reteplase, and tenecteplase. Oral anticoagulant therapies include the vitamin K antagonists and the direct oral anticoagulants (DOACs). DOACs are as effective and safe as warfarin for many indications, including prevention of stroke and peripheral arterial thromboembolism in patients who have atrial fibrillation as well as the prevention and treatment of venous thromboembolism. Warfarin remains the drug of choice for patients with prosthetic cardiac valves and high-risk antiphospholipid syndrome. Antiplatelet therapies include aspirin, the irreversible (clopidogrel, prasugrel) and reversible (ticagrelor, cangrelor) P2Y12 inhibitors, cilostazol, vorapaxar, and the platelet glycoprotein IIb/IIIa inhibitors. Aspirin is used most broadly, both as monotherapy and sometimes as dual antiplatelet therapy, typically with one of the P2Y12 inhibitors. All the P2Y12 inhibitors are oral except for cangrelor, which is an intravenous agent with a rapid onset and a half-life of several minutes. No FDA-approved reversal agents are available for platelet antagonists.
