Διπλήαντιαιμοπεταλιακή αγωγή σε ασθενείς με ΟΣΣ που υποβάλονται σε τοποθέτηση DES Dimitrios Alexopoulos, MD, FESC, FACC Professor of Cardiology Patras University Hospital Greece Patras University Hospital
Prevalence of contraindications and conditions for precaution for prasugrel administration in a real world acute coronary syndrome population. (N=646/1016) Patras University Hospital Alexopoulos et al, J Thromb Thrombolysis 2011
Montalescot G et al Lancet 2009
TRITON-TIMI TIMI 38: TIMI Major Bleeding Unrelated to CABG Surgery STEMI Cohort 15 Cumulative Incidence (%) 10 5 Clopidogrel Prasugrel 0 0 50 100 150 200 250 300 350 400 450 Days From Randomisation Differences between treatment groups are not statistically significant CABG = coronary artery bypass graft; TIMI = thrombolysis in myocardial infarction Patras University Hospital Montalescot G et al. Lancet 2009;373(9665):723-731
Patient disposition 18,758 patients enrolled in PLATO 134 patients not randomized 18,624 patients randomized NSTEMI/UA/other: 10,194 patients STEMI: 8,430 patients Randomized to ticagrelor: efficacy population N= 4,201 Safety population N=4,165 Patras University Hospital No intake of study medication: 36 patients No intake of study medication: 48 patients Randomized to clopidogrel: efficacy population N= 4,229 Safety population N=4,181
Primary endpoint: CV death, MI or stroke K-M estimated rate (% per year) 1 2 1 1 1 0 9 8 7 6 0 1 2 3 4 5 6 7 8 9 10 11 12 No. 5 at Months Ticagrel Clopidog risk 4 or 4,229 4,201 3,887 3,834 3,732 3,011 2,297 1,891 3,892 3,823 3,730 3,022 2,333 1,868 rel 3 Patras University Hospital Clopidogrel Ticagrelor 11.0 9.3 HR: 0.85 (95% CI = 0.74 0.97), p=0.0
Primary safety event: major bleeding K-M estimated rate (% per year) 10 8 6 4 2 0 Clopidogrel 9.3 9.0 Ticagrelor HR 0.96 (95% CI = 0.83 1.12), p=0.6 No. at risk Ticagr 0 1 2 3 4 5 6 7 8 9 10 11 12 Months 4,165 3,431 3,254 3,137 2,440 1,786 1,640 4,181 3,430 3,297 3,159 2,441 1,804 1,635 Patras University Hospital
2701 patients free of MACCE with DAPT at 12 months post DES randomized to clop + ASA vs ASA Patras University Hospital Park, NEJM 2010
Individualize duration of DAPT in patients at increased risk for ST End-stage renal disease/hd CTO Age <65 Prior PCI IDDM Heart failure Low body weight Patras University Hospital Kimura, RESTART Circ 2010
Bellemain-Appaix JACC 2010
Declining stent thrombosis rate Better implantation techniques Stronger platelet inhibition Stable patients Newer stents Patras University Hospital
Long term antiplatelet therapy Evidence for long term DAPT Prevention of stent thrombosis DAPT and bleeding complications Risks of DAPT discontinuation Triple therapy Special situations Patras University Hospital
TIMI major non-cabg related bleeding p=0.03 +25%* p=0.03 +25%* K-M estimated rate p=0.026 +26%* Patras University Hospital Silvain J. and Montalescot G. Circ Card Interv 2011
Individualize duration of DAPT in patients at increased bleeding risk Previous stroke/tia Elderly (>75 years) Low body weight (< 60 kg) History of previous bleeding Female gender Renal failure Patras University Hospital
Long term antiplatelet therapy of the NSTEMI patient Evidence for long term DAPT Prevention of stent thrombosis DAPT and bleeding complications Risks of DAPT discontinuation Triple therapy Special situations Patras University Hospital
No link between clopidogrel withdrawal and ST > 6 months
Predictors of early discontinuation Renal impairment, prior major haemorrage, PAD Anticoagulant therapy, private hospital, no instructions Immigrants, psychotropic drugs In-hospital major bleeding Oral anticoagulation at discharge No statin prescription Patras University Hospital Ferreira-Gonzalez, Circ 2010, Rossini, AJC 2011
Recurrent stent thrombosis Prasugrel lifelong If contra? Ticagrelor? double clopidogrel? Patras University Hospital Kimura, RESTART Circ 2010
Price, Circ 2009
Mega, JAMA Nov 2010 Patras University Hospital
Primary Endpoint: CV Death, MI, Stent Thrombosis Observed event rates are listed; P value by log rank test. Patras University Hospital
Responsiveness to clopidogrel: Any role of phenotyping and/or genotyping for what and when to stop? AHA/ACCF 2011 Class II b 1. Platelet function testing to determine platelet inhibitory response in patients with UA/NSTEMI (or, after ACS and PCI) on thienopyridine therapy may be considered if results of testing may alter management (Level of Evidence: B) 2. Genotyping for a CYP2C19 loss of function variant in patients with UA/NSTEMI (or,after ACS and with PCI) on clopidogrel therapy might be considered if results of testing may alter management. (Level of Evidence: C) Patras University Hospital
Triple antithrombotic therapy ESC/EACTS GUIDELINES 2011 Should only be given if a compelling indication exists (AF with CHADS score 2, mechanical valves, recent/recurrent Hx of deep venous thrombosis, PE) Only for the shortest period with frequent INR measurement (Target 2-2.5) Avoid DES (to restrict the duration to 1 month) Patras University Hospital
ΔΙΠΛΗ ΑΝΤΙΑΙΜΟΠΕΤΑΛΙΑΚΗ ΑΓΩΓΗ ΣΕ ΑΣΘΕΝΕΙΣ ΜΕ ΟΣΣ ΠΟΥ ΥΠΟΒΑΛΛΟΝΤΑΙ ΣΕ ΤΟΠΟΘΕΤΗΣΗ DES Δ. ΑΛΕΞΟΠΟΥΛΟΣ Καθηγητής Καρδιολογίας, Πανεπιστημιακό Νοσοκομείο Ρίου Patras University Hospital
Η διπλή αντιαιμοπεταλιακή αγωγή μετά από PCI με DES είναι απαραίτητη για: 1. 6 μήνες 2. 12 μήνες 3. >12 μήνες αν υπάρχει υψηλός ισχαιμικός κίνδυνος 4. < 12 μήνες αν υπάρχει υψηλός αιμορραγικός κίνδυνος 5. Τα 2 και 4 6. Τα 2,3,4 Patras University Hospital
Αν διακοπεί η κλοπιδογρέλη 1 έως 6 μήνες μετά εμφύτευση sirolimus DES η πιθανότητα θρομβωσης του stent στα επόμενα 2 χρόνια είναι: 1. 1% 2. 2% 3. 3% 4. 8% 5. Κανένα από τα ανωτέρω Patras University Hospital
Η πρασουγκρέλη πρέπει /μπορεί να δίδεται σε ασθενείς: 1. >75 ετών 2. < 60 kg 3. σε διαβητικούς >75 ετών 4. σε μη διαβητικούς <75 ετών 5. Τα 3 και 4 Patras University Hospital
Η τικαγρελόρη στην μελέτη PLATO : 1. Μείωσε το σύνθετο σημείο θάνατος, έμφραγμα, εγκεφαλικό σε σχέση με την κλοπιδογρέλη 2. Μείωσε την θνητότητα σε σχέση με την κλοπιδογρέλη 3. Είχε ίδιες με την κλοπιδογρέλη αιμορραγίες μη σχετιζόμενες με αορτοσταφανιαία παράκαμψη 4. Όλα τα ανωτέρω 5. Τα 1 και 2 Patras University Hospital