Γρηγόριος Τσίγκας Επεμβατικός καρδιολόγος- Επιμελητής Α

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1 Φαρμακολογία στα οξέα στεφανιαία σύνδρομα Διάρκεια διπλής αντιαιμοπεταλιακής αγωγής Γρηγόριος Τσίγκας Επεμβατικός καρδιολόγος- Επιμελητής Α Πανεπιστημιακό Νοσοκομείο Πατρών Διευθυντής: Γ. Χάχαλης

2 ΣΥΓΚΡΟΥΣΗ ΣΥΜΦΕΡΟΝΤΩΝ Λήψη τιμητικής αμοιβής (honorarium): GALENICA, MINERVA, BAYER-ELPEN, LILLY

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5 ΔΙΑΡΚΕΙΑ STENTS ΚΛΙΝΙΚΟ ΣΥΝΔΡΟΜΟ

6 Monthly rates of the primary ischemic and primary bleeding end points Patient-level data from PROTECT and PROTECT US, 9727 Pts Matteau aa. Et al. Am J Cardiol 2015;116:686e693

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13 OPTIDUAL continuing clopidogrel would be superior to stopping clopidogrel at 12 months following drugeluting stent (DES) implantation. post hoc Analysis 4 years Kaplan Meier curves for primary outcome of net adverse clinical events (defined as the composite of death, myocardial infarction, stroke, or major International Society on Thrombosis and Haemostasis bleeding).

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15 Elmariah S, Mauri L, Doros G, O Neill KE, Steg PG, Kereiakes DJ, Yeh RW. Extended Duration Dual Antiplatelet Therapy and Mortality: A Systematic Review and Meta-analysis. The Lancet 2015 Feb 28;385(9970):792-8

16 Long-term dual antiplatelet therapy for secondary prevention patients were followed over a mean 31 months high-risk patients with a history of prior myocardial infarction (MI) J.A. Udell et al. European Heart Journal (2016) 37,

17 Risk of All-Cause Mortality With More Intensive Antiplatelet Therapy for Long term Secondary Prevention in Patients With Prior Myocardial Infarction 6 fewer MIs and 3 fewer stent thromboses but 5 additional major bleeds per 1,000 patients JAMA Cardiology Published online August 10, 2016

18 2.2X increase in the MACE rate after stopping DAPT at 30 months Stopping DAPT removes a strong protective factor against MI, even after 30 months or therapy

19 Remarkable comments acting as compass 1. How well has the patient tolerated his or her antiplatelet regimen during the first year after their MI? Only patients who have tolerated and adhered to therapy during the past 12 months should be considered for prolonged therapy. 2. Does the patient have any characteristics that place him or her at high risk of bleeding? Prolonged therapy should be avoided in patients with a bleeding diathesis, a major recent bleeding episode, intracranial pathology, or who need anticoagulation. 3. What is the patient s risk for ischemic events? Although prolonged intensive antiplatelet therapy is effective at reducing MACE across the MI population, such therapy may be particularly attractive in patients with characteristics associated with heightened ischemic risk such as diabetes, multivessel coronary artery disease, renal dysfunction, or peripheral arterial disease In whom there are greater absolute risk reductions in MACE and/or notable reductions in cardiovascular mortality.

20 Η αβεβαιότητα χρειάζεται καθοδήγηση

21 Παράγοντες που χρησιμοποιούνται για να εξαχθεί το DAPT Score 23 decision tool therapy beyond 1 year Simultaneously accounting for patient risks of ischemia AND bleeding events with continued therapy

22 Cumulative Incidence of ST/MI Cumulative Incidence of GUSTO Moderate/ Severe Bleed Cumulative Incidence of MACCE 24 Continued Thienopyridine vs. Placebo DAPT Score <2 (Low); N=5731 Stent Thrombosis or MI 10% 8% Continued Thienopyridine Placebo MACCE 10% 8% Continued Thienopyridine Placebo 6% 6% 4% 1.7% vs. 2.3% P=0.07 4% 3.7% vs. 3.8% P=0.73 2% 2% 0% Months After Enrollment 0% Months After Enrollment GUSTO Moderate/ Severe Bleeding 10% 8% 6% 4% 2% Continued Thienopyridine Placebo 3.0% vs. 1.4% P< % Months After Enrollment

23 Cumulative Incidence of ST/MI Cumulative Incidence of GUSTO Moderate/ Severe Bleed Cumulative Incidence of MACCE 25 Continued Thienopyridine vs. Placebo DAPT Score 2 (High); N=5917 Stent Thrombosis or MI 10% 8% Continued Thienopyridine Placebo MACCE 10% 8% Continued Thienopyridine Placebo 6% 4% 2.7% vs. 5.7% P< % 4% 4.9% vs. 7.6% P< % 2% 0% Months After Enrollment 0% Months After Enrollment GUSTO Moderate/ Severe Bleeding 10% 8% 6% 4% 2% Continued Thienopyridine Placebo 1.8% vs. 1.4% P=0.26 0% Months After Enrollment

24 Duration of dual antiplatelet therapy after coronary artery stenting: where is the sweet spot between ischaemia and bleeding?

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28 Near future several trials are now testing the benefit and safety of longterm ticagrelor monotherapy vs dual antiplatelet therapy including GLOBAL LEADERS (NCT ) and TWILIGHT (NCT ).

29 ΣΥΜΠΕΡΑΣΜΑΤΑ Η σύσταση «one-size-fits-all " για τη διάρκεια της DAPT είναι λάθος Είναι σαφές από την σύγχρονη βιβλιογραφία ότι τα στεντς χρειάζονται βραχυχρόνια θεραπεία για την πρόληψη της θρόμβωσης, αλλά οι ασθενείς μακροχρόνια θεραπεία Η βέλτιστη διαρκεια της DAPT είναι >12m εως Εάν οι ασθενείς έχουν την τάση να ματώνουν, μπορούν να σταματήσουν την DAPT σε 6 μήνες Η βέλτιστη διάρκεια της διπλής αντιαιμοπεταλιακής αγωγής πρέπει να εξατομικεύεται για κάθε ασθενή, εξισορροπώντας τα οφέλη από την μείωση του ισχαιμικού κινδύνου και τους κινδύνους της αιμορραγίας

30 ΣΑΣ ΕΥΧΑΡΙΣΤΩ ΓΙΑ ΤΗΝ ΠΡΟΣΟΧΗ ΣΑΣ