atriumfibrilleren en coronairlijden
play

atriumfibrilleren en coronairlijden Jur ten Berg, MD, MSc, PhD, - PowerPoint PPT Presentation

Sep 07, 2022 •111 likes •407 views

Casuistiek antitrombotische therapie bij atriumfibrilleren en coronairlijden Jur ten Berg, MD, MSc, PhD, FESC, FACC May 2017 St Antonius ziekenhuis, Nieuwegein, The Netherlands Disclosures Advisory/consulting/speakers fees : AstraZeneca,

  1. Casuỉstiek antitrombotische therapie bij atriumfibrilleren en coronairlijden Jur ten Berg, MD, MSc, PhD, FESC, FACC May 2017 St Antonius ziekenhuis, Nieuwegein, The Netherlands

  2. Disclosures • Advisory/consulting/speakers fees : AstraZeneca, Eli Lilly, Daiichi Sankyo, The Medicines Company, Accumetrics, Boehringer Ingelheim, BMS, Pfizer, Bayer, Ferrer • Research grants : ZonMw, AstraZeneca • RE-DUAL study : executive scientific committee

  4. 4

  5. Why change duration of DAPT after ACS and PCI? Longer: Shorter: • Event rate after standard 1 year DAPT • One year DAPT after ACS based on remains high CURE and CURE-PCI with predominantly conservative treatment and when stented mostly BMS or 1st generation DES • 2nd generation DES safer (less ST) • Stronger more effective P2Y12 inhibitors while ischemic risk diminishes over time • More patients at high risk for bleedings (elderly, OAC) 5

  6. Shorter : 2nd generation DES safer 5 Crude rates (unadjusted) Xience exp. N=13,266 ST 0.86% with different duration of FU All stents implanted 2007 – August 24 2016 8 Resolute I. N=6,687 ST 0.85% Orsiro N=7,644 ST 0.59% 3 Promus P N=24,831 ST 0.51% 2 Ultimaster N=2,266 ST 0.49% Onyx N=18,709 ST 0.39% 1 Synergy N=14,979 ST 0.26% 0 0 1 2 3 4 5 SCAAR S.James 6

  7. Longer : HELICON study 1-year event-free MI survivors (n=76,687) Cumulative 3 year incidence of CV death, MI or stroke (%) 20 ~1 in 5 patients, % Event-free for 1 year post-MI, will suffer an MI, stroke or CV death within 3 years CV, cardiovascular; MI, myocardial infarction. Jernberg, T. et al. Eur Heart J 2015: doi:10.1093/eurheartj/ehu505 7

  8. Casus I • Man 50 jaar, hypercholesterolemie, rookte tot electieve PCI van mid-LAD met 2 e generatie DES (3.0x15) 11-1- 2018 a)P2Y12 remmer 6 maanden b)P2Y12 remmer 12 maanden c) P2Y12 remmer > 12 maanden 8

  9. Shorter DAPT (≤ 6 M) Most stable CAD, most 2nd generation DES, all non-inferiority design 2 nd gen Design ACS Trial N Primary Endpoint Mean Study DAPT, mth % age DES Outcome 6 vs 12 40 ISAR-SAFE 4,000 Composite of death, MI, stroke, ST, or TIMI major bleeding at 15 67 72 NI months after PCI 6 vs 12 24 ITALIC 1,822 Composite of death, MI, repeat TVR, stroke or TIMI major bleeding at 62 NI 100 12 months after PCI 6 vs 12 38 SECURITY 1,399 Composite of cardiac death, MI, stroke, ST, or BARC 3 or 5 bleeding at 65 NI 100 12 months after PCI 3 vs 12 32 OPTIMIZE 3,119 Composite of death, MI, stroke, or major bleeding at 12 months after 61 100 NI PCI 6 vs 24 75 PRODIGY 1,970 Composite of death, MI, or cerebrovascular accidents at 24 months 68 50 NI after PCI 3 vs 12 55 RESET 2,117 Composite of cardiac death, MI, ST, ischemia-driven TVR, or bleeding 62 85 NI at 12 months after PCI 6 vs 12 51 EXCELLENT 1,433 Composite of cardiac death, MI, or TVR at 12 months after PCI 63 NI 75 BARC, Bleeding Academic Research Consortium; EXCELLENT, Efficacy of Xience/Promos versus Cypher to reduce late loss after stenting; ISAR-SAFE, Randomized, double-blind, placebo-controlled trial of 6 vs 12 months clopidogrel therapy after implantation of a drug-eluting stent; ITALIC, Is there a life for DES after discontinuation of clopidogrel; OPTIMIZE, Optimized duration of clopidogrel therapy following treatment with the Endeavor Zotarolimus-eluting stent in the real world clinical practice; PRODIGY, Prolonging DAPT in patients with coronary artery disease after graded stent-induces intimal hyperplasia; RESET, A new strategy regarding discontinuation of dual antiplatelet/ real safety and efficacy of a 3-month DAPT following zotarolimus-eluting stents implantation; SECURITY, Second-generation drug-eluting stent implantation followed by 6- vs 12 month DAPT, MI myocardial infarction; NI, non-inferior; 9 ST, stent thrombosis; TIMI, Thrombolysis in Myocardial Infarction; TVR, target vessel revascularization; PCI, percutaneous coronary intervention. Montalescot et al. J Am Coll Cardiol 2015;66:832-47

  10. Myocardial infarction: 3-6 months vs 12 months Meta-analysis for the 2016 ACC/AHA guideline focused update Prolonged Short Trial Events Events OR 95% CI 7 / 722 EXCELLENT (6 vs 12 mo) 721 13 / 0.53 (0.21-1.35) 4 / 1059 2.01 RESET (3 vs 12 mo) 1058 2 / (0.37-11.0) 42 / 1563 0.86 OPTIMIZE (6 vs 12 mo) 1556 49 / (0.56-1.30) 15 / 682 SECURITY (6 vs 12 mo) 717 16 / 0.89 (0.44-1.81) 14 / 1997 ISAR-SAFE (6 vs 12 mo) 2003 13 / 1.07 (0.50-2.29) Bayesian hierarchical meta analysis 0.90 (0.60-1.30) 82 / 6023 0.87 Fixed effect model 6055 93 / (0.65-1.18) Random effect model 0.87 (0.65-1.18) 0.2 5 10 Short better Prolonged better 0.1 0.5 1 2 Circulation. 2016;134:e156 – e178. 10

  11. Major hemorrhage: 3-6 months vs 12 months Meta-analysis for the 2016 ACC/AHA guideline focused update Prolonged Short Trial 95% CI Events Events OR EXCELLENT (6 vs 12 mo) 721 (0.37-11.0) 4 / 2 / 722 2.01 RESET (3 vs 12 mo) 1058 (0.61-15.0) 3.01 6 / 2 / 1059 OPTIMIZE (6 vs 12 mo) 1556 (0.62-3.18) 1.41 14 / 10 / 1563 SECURITY (6 vs 12 mo) 717 (0.57-6.38) 8 / 4 / 682 1.91 ISAR-SAFE (6 vs 12 mo) 2003 (0.33-4.65) 5 / 4 / 1997 1.25 Bayesian hierarchical meta analysis (0.89-2.90) 1.67 Fixed effect model 6055 (0.99-2.84) 1.67 37 / 22 / 6023 Random effect model (0.97-2.82) 1.65 Prolonged better 0.5 10 0.1 0.2 1 2 5 Short better Circulation. 2016;134:e156 – e178. 11

  12. 12

  13. Casus II • Man 55 jaar, DM II, hypertensie met GFR = 48 ml/min, rookt nog • 2017- 1 pPCI RCA voor OWI start asa+ticagrelor (2x90 mg) • 2017- 1 PCI DES proximale LAD, PCI Cx en diffuus RCA • 2018- 1 geen AP, geen bloeding a) P2Y12 remmer (ticagrelor) had al gestopt moeten zijn b) Nog jaren continueren 13

  14. DAPT trial, Not-Stent Thrombosis Myocardial Infarction % 10 95% CI HR P value n 12 months 8 0,45 – 0,78 0,59 <0,001 9.961 30 months 6 55% of the MI 2,9 benefit is NOT 4 related to stent thrombosis 1,8 0 18 21 24 27 0 12 15 30 33 Maanden na randomisatie 14 Mauri L, et al. Am Heart J 2010;160:1035-1041.e1

  15. age of 65 years or older, diabetes mellitus requiring medication, a second prior spontaneous myocardial infarction, multivessel coronary artery disease, or chronic renal dysfunction GFR< 60 ml/min N= 21.000

  17. PEGASUS-TIMI 54 Bleeding Ticagrelor, 90 mg 5 Ticagrelor, 60 mg Placebo 4 <0.001 3 2.6 2.3 <0.001 NS NS NS 2 1.3 1.2 1.1 1 0.7 0.6 0.6 0.6 0.6 0.5 0.4 0.1 0.3 0.3 0 TIMI Minor Fatal bleeding TIMI Major Fatal bleeding ICH or ICH 17 Bonaca MP et al. Am Heart J 2014; 167:437-44

  18. Prolonged DAPT post AMI ASA only Extended DAPT Rel. Events/Total weight HR 95% CI Events/Total 2006 CHARISMA MI cohort 1943 21.4% 125 1903 162 0.77 (0.61-0.98) 2012 PRODIGY 733 13.3% 63 732 69 0.91 (0.65-1.28) 2014 ARCTIC interruption 167 1.0% 3 156 4 0.79 (0.18-3.51) 2014 DAPT 1771 14.6% 0.52 59 1805 108 (0.38-0.72) 2015 DES-LATE 1551 12.9% 56 1512 66 0.85 (0.60-1.21) 2015 PEGASUS-TIMI 54 7067 36.8% 980 14095 578 0.84 (0.76-0.94) 1 0.5 5 2 0.2 Major adverse cardiovascular events 0.78 (0.67-0.90) Cardiovascular death 0.65 (0.74-0.98) Absolute 0.3% Myocardial infarction 0.70 (0.55-0.88) Stroke 0.81 (0.68-0.97) Stent thrombosis (definite, probable) 0.50 (0.28-0.89) Major bleeding 1.73 (1.19-2.50) Non-cardiovascular death 1.03 (0.86-1.23) All-cause death 0.92 (0.83-1.03) 0.5 2.5 1 18 Udell, prolonged DAPT post AMI. Meta analysis EHJ 2016

  19. Casus II • Man 55 jaar, DM II, hypertensie met GFR = 48 ml/min, rookt nog • 2017- 1 pPCI RCA voor OWI start asa+ticagrelor (2x90 mg) • 2017- 1 PCI DES proximale LAD, PCI Cx en diffuus RCA • 2018- 1 geen AP, geen bloeding a) P2Y12 remmer (ticagrelor) had al gestopt moeten zijn b) Nog jaren continueren PEGASUS: age of 65 years or older, diabetes mellitus requiring medication, a second prior spontaneous myocardial infarction, multivessel coronary artery disease, or chronic renal dysfunction GFR < 60 ml per minute. DAPT: no event first year, score 3 (DM, prior MI or PCI, smoking) 19

  20. 20

  21. 21

  22. 22

  23. Hart Beter

  24. Patient: Jan Patient history Medical history • Hypertension (2002) • Type 2 diabetes mellitus (2003) • Peripheral artery disease • Renal impairment (GFR = 45 mL/min) • TIA (2011) • Paroxysmal NVAF (diagnosed 2011; CHA 2 DS 2 -VASc: 7) Personal information • Medications Beta blocker • Sex Male Statin • ACE inhibitor Age 85 years • Antidiabetics Blood pressure 161/89 mmHg • NOAC since 2013 (because of labile INR/low TTR) Pulse 69 bpm • Presentation Heavy chest pain (40 min, previous night) • Oxygen saturation 97% Pain-free at presentation

  25. Q What is the optimal antithrombotic regimen after stenting? 1. Dual 2. Triple therapy

Recommend

More recommend