Angioplastie lective haut risque thrombotique Philip Urban Hpital - PowerPoint PPT Presentation

Angioplastie élective à haut risque thrombotique Philip Urban Hôpital de la Tour Genève

Lesion & Procedure Patient Stent DAPT intensity & duration

DAPT & stent choice for SCAD 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease. Valgimigli et al EHJ 2017

High-risk features of stent-driven recurrent ischaemic events 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease. Valgimigli et al EHJ 2017

Complex PCI in DAPT trials after PCI Giustino G et al. JACC 2016; 68: 1851-64 1680 patients of 9577 (17.5%) underwent complex PCI Data from PRODIGY, OPTIMIZE, RESET, EXCELLENT, SECURITY, ITALIC.

Complex PCI in DAPT trials after PCI Giustino G et al. JACC 2016; 68: 1851-64

Two elephants who were not in that room … SVG ISR PRODIGY, OPTIMIZE, RESET, EXCELLENT, SECURITY and ITALIC included only native coronary de novo lesions

• 224 patients treated for ISR in the PRODIGY trial • 114 short DAPT (6 months) • 110 long DAPT (24 months) • Primary EP: death, MI, CVA at 24 months 16.7% 8.3% P=0.034 J Am Coll Cardiol 2014;63:506 – 12

Effect of pre-treatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study PCI - CV Death or MI from CV Death or MI from Randomization to End Randomization to End Relative Risk Relative Risk Plac Plac 2N 2N Clopid Clopid 2658 NSTEMI patients Diabetes Diabetes 504 504 16.5 16.5 12.9 12.9 No Diabetes No Diabetes 2154 2154 11.7 11.7 7.9 7.9 4 weeks Aspirin + Clopidogrel post PCI only PCI in 1st Hosp. PCI in 1st Hosp. 1730 1730 12.0 12.0 8.3 8.3 vs. PCI After 1 st st Hosp. PCI After 1 Hosp. 928 928 13.8 13.8 9.8 9.8 Preloading and long term DAPT H/O CABG H/O CABG 332 332 21.7 21.7 9.6 9.6 No H/O CABG No H/O CABG 2326 2326 11.2 11.2 8.7 8.7 Primary EP: PCI £ 72 h Rand CV death, MI or TVR < 30 days PCI 72 h Rand 544 544 13.5 13.5 8.5 8.5 PCI > 72 h Rand PCI > 72 h Rand 2114 2114 12.3 12.3 8.9 8.9 0.2 0.4 0.6 0.8 1.0 1.2 better Placebo better Placebo better Clopidogrel Clopidogrel better Mehta SR et al. Lancet 2001:358:527-33

J Am Coll Cardiol 2012;60:2357 – 63 411 patients event-free at the time of clopidogrel cessation “A clustering of events was observed in the initial 0 to 90 days after clopidogrel cessation in all treatment durations of clopidogrel investigated after SVG PCI”

The DAPT Score Distribution of DAPT Scores among all Variable Points randomized subjects in the DAPT Study Patient Characteristic Age 30% ≥ 75 -2 Percentage of 25% 65 - <75 -1 Patients 20% < 65 0 Diabetes Mellitus 1 15% Current Cigarette Smoker 1 10% 5% Prior PCI or Prior MI 1 CHF or LVEF < 30% 2 0% -2 -1 0 1 2 3 4 5 6 7 8 9 10 Index Procedure Characteristic DAPT Score MI at Presentation 1 Vein Graft PCI 2 Standard DAPT (12 months) Extended DAPT Stent Diameter < 3mm 1 13

P2Y12 SWITCHING 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease. Valgimigli et al EHJ 2017

Switching “up” “While no RCTs investigating the use of ticagrelor or prasugrel instead of clopidogrel in stable CAD patients undergoing PCI exist, this treatment option may be considered in selected patients in whom the use of clopidogrel is unsatisfactory based on prior clinical outcomes or potentially associated with higher risk of ischaemic events than bleeding recurrences”. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease. Valgimigli et al EHJ 2017

Assessment of Loading With the P2Y12 Inhibitor Ticagrelor or Clopidogrel To Halt Ischemic Events in Patients Undergoing Elective Coronary Stenting (ALPHEUS). Johanne Silvain, Gilles Montalescot, et al. 1900 elective high risk PCI candidates on aspirin High risk • Age > 75 • Renal insufficiency (< 60 ml/min) • Diabetes Mellitus Ticagrelor pre-PCI Clopidogrel pre-PCI Primary endpoint: • BMI >30 • loading + 30 days loading + 30 days History of ACS in the past 12 months MI or myocardial damage • LVEF < 40% and/or CHF at 48h or discharge • Multivessel disease • Multiple stents needed • Secondary endpoint: Total stent length envisioned > 30mm, • Left main stenting BARC 3-5 bleeding at 48h • Bifurcation stenting or discharge • ACC/AHA type B2 or C lesion • Stenting of venous or arterial graft

A delicate balance thrombosis bleeding

2466 HBR patients randomised to BA-9 DCS or BMS One month DAPT only for all Primary Endpoints and Major Bleeding at 1 Year DCS BMS Efficacy (cd-TLR) Safety (cardiac death, MI, ST) Bleeding (BARC 3-5 ) % % 12 % Cumulative Percentage with Event 9.8% 15 12.9% 9 7.3% 12 9 6 7.2% 9.4% 6 5.1% 3 3 HR 0.71, (95% CI = 0.56 ‒ 0.91) p for superiority < 0.001 p < 0.0001 for non-inferiority HR 0.50, (95% CI = 0.37 ‒ 0.69) p = 0.005 for superiority 0 0 0 90 180 270 390 Days 0 90 180 270 390 Days Urban P et al. N Engl J Med 2015;373:2038-47

Integer risk score Covariates Score Multivessel disease -4 MI (at admission or previously) -4 BMS (vs. DCS) -3 Plasma creatinine > 150 μmol /l -2 Age > 75 -1 Planned oral anticoagulants +6 Hb > 8.5 mmol/l (>136 g/L) 0 Hb 7.5 – 8.4 mmol/l (120 - 136 g/L) +3 Hb 6.5 – 7.4 mmol/l (104 - 119 g/L) +6 Hb 5.5 – 6.4 mmol/l ( 88 - 103 g/L) +9 Hb < 5.4 mmol/l (< 88 g/L) +12

Predicted Individual Patient Risks of Bleeding & Thrombotic Events Thrombotic risk > 2x bleeding risk n=444 (20.5%) Integer score < -5 Integer score > +5 Bleeding risk > 2x thrombotic risk N=210 (9.7%)

High Thrombotic Risk (HTR) elective angioplasty • Several baseline, angiographic and procedural factors are known to be associated with an increased thrombotic risk (MI and/or ST) • Such “HTR” patients may benefit from:  Switching from Clopidogrel to more powerful P2Y12 inhibitors  Prolonged DAPT beyond 6 months, to one year or more (SVG in particular) • But the balance of bleeding and thrombotic risks needs to be assessed for each individual patient prior to making a decision about antithrombotic treatment

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