Cardiovasculaire Geneeskunde.nl

Antistolling na myocardinfarct: uit te meten?

Slides (presentatie) - Mar. 3, 2011


Dia 2

Mortality in hospital and at 6 months in low, intermediate and high risk categories in registry populations according to the GRACE Risk score http://www.outcomes.org/grace

Question: Strategy ?

Relative risk of all cause of mortality

Management Strategy

Time to catheterization (hrs)

Dia 8

A.S.A.P < 24 h vs delayed > 36h - ACS met 2/3 > 60 y, pos marker (76%), ischemic ECG (80%) and revasc possible

No early hazard!

GRACE > 141 14% 21% p=0.009 Major bleeds 3.1 3.5% p=0.53

Early (≤24 h, median=14h) or delayed intervention ( ≥36 h, median=50h) N=3000

Early (≤24 h, median=14h) or delayed intervention ( ≥36 h, median=50h)

Why not immediately “STEMI-like”?

ABOARD study design

Index ACS event

In-hospital medications

Time to catheterization (hrs)

Primary EP (peak of troponin I)

Composite Ischemic Endpoints at 1 month

Safety outcomes at 1 month

Hospital stay

Summary: TIMACS and ABOARD

Question: Strategy ?

Q: GPIIbIIIa inhibitors ? When ?

GPIIbIIIa Inhibitors

Efficacity GPIIBIIIA in NSTE ACS only if PCI !!!

N=2022

If GPIIbIIIa: - Upstream for all high risk NSTE ACS ? - or selectively downstream if PCI ?

N=9492

Delayed Provisional GPIIbIIIa: Same Ischemic benefit Lower bleeding risk

30-day Death or MI Prespecified Subgroups

Summary for GPIIbIIIa

Q: GPIIbIIIa inhibitors ? When ?

Q: Antiplatelet Therapy: P2Y12 inhibitors in CCU ?

Alternatives Molecules

Montalescot et al. JACC 2006

Q: Antiplatelet Therapy: P2Y12 inhibitors in CCU ?

Antiplatelet Drugs

Study Design, Flow and Compliance

Clopidogrel: Double vs Standard Dose Primary Outcome and Components

Clopidogrel: Double vs Standard Dose Primary Outcome: PCI Patients

Clopidogrel Double vs Standard Dose Bleeding PCI Population at 30 days

Conclusions Clopidogrel Dose Comparison

ACS (STEMI or UA/NSTEMI) & Planned PCI

Primary Endpoint: CV Death,MI,Stroke

Balance of Efficacy and Safety

ISCHEMIC BENEFIT: subgroups

Diabetic Subgroup

Ischemic Risk

BLEEDING RISK: subgroups

Tailored for Bleeding Risk ?

P2Y12 inhibitors for PCI/ACS in 2011

Q: Antiplatelet Therapy: P2Y12 inhibitors in CCU ?

Platelet Function Tests

Composite of death, non-fatal myocardial infarction, definite stent thrombosis and stroke POPular study JAMA 2010

Cut-Off values Based on Clinical Endpoints in Prospective Studies

Risk for recurrent events concentrated in patients with highest on-treatment reactivity

POPular Risc Score

Ticagrelor compared with clopidogrel in patients with acute coronary syndromes – the PLATO trial

Ticagrelor (AZD 6140): an oral reversible P2Y12 antagonist

PLATO study design

K-M estimate of time to first primary efficacy event (composite of CV death, MI or stroke)

Time to major bleeding – primary safety event

Non-CABG and CABG-related major bleeding

Safety = TIMI Major Non-CABG Bleeds (12-15 months)

Conclusions

2011 CURRENT vs PLATO vs TRITON

Platelet Aggregation at 4 hours

TRITON and PLATO

Safety = TIMI Major Non-CABG Bleeds (12-15 months)

Tailor-made medicine?

Marked interindividual response to antiplatelet drugs

Residual or On-Treatment Platelet Reactivity

Do Platelet Function Assays Predict Clinical Outcomes in clopidogrel pretreated patients undergoing elective PCI The POPular-study. JAMA 2010;303:754-62

Tests more physiological shear-dependent

POPular Risk Score

Rate of CABG patients and TIMI Major Bleeds

Summmary: P2Y12 inhibition for tomorrow

Compliance and ST

With more potent P2Y12 inhibitors: How to reduce Bleeding Risk in ACS ?

Low Dose of Aspirin

ASA Dose Comparison Primary Outcome and Bleeding

Use of PPI

Radial Access

Case

3/3/2011

3/3/2011

Similar for DES

MACC with BMS and non-cardiac surgery N=899

Bleeds with DES and Non-cardiac Surgery

Bridging?

Summary for ACS: 2011

Discharge therapy

Tailored Therapy PCI in ACS ?

Discontinue antithrombotica

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