◆ 10/21/17 Disclosures Updates in No Conflicts of Interest Acute Coronary Syndromes Krishan Soni, MD, MBA, FACC Assistant Professor of Medicine Krishan.soni@ucsf.edu Division of Cardiology Updates in Acute Coronary Syndromes Updates in Acute Coronary Syndromes TOPICS ■ Dual Antiplatelet Therapy (DAPT) ■ Major Society Guideline ◆ Choice and Dosing updates 2016-2017 ◆ Duration ◆ Triple Therapy ■ Clinical Trials Published ◆ Cessation for Surgery 2016-2017 ◆ Management in the Bleeding Patient ■ Regulatory News and ■ ACS Performance Metrics in 2017 Events ◆ 1
◆ 10/21/17 Strength of Guideline Recommendations Acronyms ■ ACS : Acute Coronary Syndrome ■ BMS: Bare Metal Stent ■ CAD : Coronary Artery Disease ■ CABG: Coronary Artery Bypass Graft Surgery ■ DAPT : Dual Antiplatelet Therapy ■ DES: Drug Eluting Stent ■ PCI : Percutaneous Coronary Intervention ■ PPI: Proton Pump Inhibitor ■ SIHD : Stable Ischemic Heart Disease ■ TAVR : Transcatheter Aortic Valve Replacement Updates in Acute Coronary Syndromes TOPICS ■ Dual Antiplatelet Therapy (DAPT) ◆ Choice and Dosing ◆ Duration ◆ Triple Therapy ◆ Cessation for Surgery ◆ Management in the Bleeding Patient ■ ACS Performance Metrics in 2017 ◆ 2
◆ 10/21/17 A 65 yo male with DM, HTN, HL presents with acute Antiplatelet Agents onset substernal chest pain for three hours. Troponin is 1. EKG demonstrates sinus rhythm with Aspirin Clopidogrel Prasugrel Ticagrelor lateral T wave inversions. He is now chest pain free (Plavix) (Effient) (Brilinta) and awaiting invasive angiography in the AM. Which Indication ACS ACS Post PCI ACS Post PCI Post PCI Post PCI antiplatelet regimen do you start? Stroke Stroke PVD PVD A. Aspirin 81 daily alone Dose 325 mg 300-600 mg 60 mg 180 mg Load 81 mg 75 mg 10 mg 90 mg B. Aspirin 81 daily + Clopidogrel 75 daily Maintenance DAILY DAILY DAILY BID 2 nd gen 2 nd gen C. Aspirin 81 daily + Ticagrelor 90 mg BID Class NSAID CTPT thienopyridine thienopyridine D. Aspirin 81 mg daily + Prasugrel 10 mg daily (PRODRUG) (PRODRUG) E. Call your friendly cardiology consultant Mechanism IRREVERSIBLE IRREVERSIBLE IRREVERSIBLE REVERSIBLE COX 1 P2Y12 P2Y12 P2Y12 Peak Effect 1-3 hours 6 hours 4 hours 2 hours CYP Metab NA 2C19 3A4 3A4/5 Aspirin Dosing in Patients with Which P2Y12 Agent should I Recommend? Coronary Artery Disease (CAD) For Medically Recommended ◆ Higher doses of aspirin are associated with Managed ACS over bleeding and no increased anti-ischemic benefit ◆ When used with ticagrelor (Brilinta), aspirin doses For ACS with Recommended of >100 mg are contraindicated PCI over ◆ 3
◆ 10/21/17 During angiography, the patient is found Other Pearls Regarding P2Y12 Inhibitors to have an 80% mid LAD lesion which is ■ Ticagrelor treated with a stent. How long should he ◆ can cause dyspnea and bradycardia remain on DAPT after stent placement for NSTEMI? ■ Prasugrel A. 3 months ◆ may be less effective in patients < 60 kg B. 6 months and > 75 years of age C. 12 months ◆ should not be given until after invasive D. More information angiography (Class III) needed ◆ do not give to patients with a history of E. As long as TIA or stroke (Class III) possible Duration of Dual Antiplatelet Therapy Duration of Dual Antiplatelet Therapy (DAPT) (DAPT) in Patients with ACS Duration of DAPT depends on: Acute Coronary ■ ◆ Underlying condition Syndromes (ACS) ◆ Treatment provided Stopping 1 year early Stable Ischemic Heart Acute Coronary Syndromes at 6 months Disease (SIHD) (ACS) ◆ 4
◆ 10/21/17 Duration of Dual Antiplatelet Therapy When should DAPT therapy be (DAPT) in Patients with SIHD continued for LONGER Duration? Stable Ischemic Heart Disease (SIHD) Risk of Ischemia Risk of Bleeding Stopping early at 3 months PCI with Bare PCI with Metal Drug Stent Eluting (BMS) Stent (DES) 1 MONTH 6 MONTHS The DAPT Score can guide risk / benefit You are writing the discharge of longer therapy medication list and receive a page from Pharmacy Score ≥ 2 Favorable benefit/risk For prolonged DAPT “Ticagrelor is not covered by this patient’s insurance and he wont be able to Score <2 NOT receive the medication at Favorable benefit/risk home unless he pays out of pocket” For prolonged DAPT What do you do? Our patient has a score of 1. 12 months of DAPT should be adequate ◆ 5
◆ 10/21/17 Switching Between Oral P2Y12 Inhibitors Switching Between Oral P2Y12 Inhibitors Acute Settings (ACS) Stable Settings (SIHD) ESC Class IIb recommendation What’s the update on triple therapy? The patient returns to the Emergency Room 7 days later with shortness of breath. An EKG reveals that American Guidelines he is now in Atrial Fibrillation. Troponin is normal. CHADS2Vasc score is 4. What regimen to you place him on? A. Aspirin + Ticagrelor (No change) B. Aspirin + Ticagrelor + Coumadin C. Aspirin + Clopidogrel + Coumadin D. Clopidogrel + Coumadin E. Clopidogrel + Rivaroxaban ◆ For patients who require triple therapy: F. That’s a hard choice! ◆ Use Coumadin (keep INR at low end of range) ◆ Use Clopidogrel (NOT Prasugrel/Ticagrelor) ◆ Use low dose aspirin ◆ Consider PPI ◆ 6
◆ 10/21/17 Timeline for Triple Therapy What’s the update on triple therapy? European Guidelines European Guidelines ◆ Major differences ◆ NOACs can be used (IIa indication) ◆ Consider lower dose rivaroxaban (15 mg daily) Perioperative Management and Timing 72 yo man underwent PCI with a drug eluting stent of Non Cardiac Surgery to the LAD 2 months ago. He now has severe knee osteoarthritis and is asking you when he can have surgery. How long after his stent should he wait? A. 1 month B. 3 months Wait at least 3 months and C. 6 months preferably 6 D. 12 months months after PCI with DES E. He should be managed medically indefinitely Wait 30 days after PCI with BMS ◆ 7
◆ 10/21/17 Perioperative Management and Timing Perioperative Management and Timing of Non Cardiac Surgery of Non Cardiac Surgery ◆ How long before surgery should DAPT be stopped? ◆ CONTINUE ASPIRIN if possible! ◆ During perioperative period: ◆ Continue aspirin if possible ◆ Restart P2Y12 as soon as possible What to do when the patient bleeds on What to do when the patient bleeds on DAPT? DAPT? ■ Stop DAPT, continue with SAPT (P2Y12) preferred ■ If bleeding persists, stop all meds ■ Once bleeding ceased, re-evaluate need for DAPT ■ If restarted use less potent agent for minimal duration ◆ 8
◆ 10/21/17 Key Points Regarding DAPT (1/3) Key Points Regarding DAPT (2/3) Dose of Aspirin for all patients is 81 mg daily Choice of Agents: ■ ■ Duration of DAPT: ◆ Medical Management of ACS: Ticagrelor > Plavix ■ ◆ PCI in ACS: Ticagrelor or Prasugrel > Plavix ◆ ACS Patients: 1 YEAR for ALL (with/without stent) ◆ Do NOT USE Prasugrel if history of stroke or TIA ◆ SIHD (Stable Ischemic Heart Disease) Patients: ✦ Drug Eluting Stent (DES): 6 MONTHS ✦ Bare Metal Stent (BMS): 1 MONTH Triple Therapy: ■ Stopping Early: ◆ Short Duration ■ ◆ DAPT could be stopped 3 months after DES (drug ◆ Use clopidogrel/coumadin eluting stent) for high bleeding risk patients ◆ Target INR 2-2.5 Longer Therapy: ◆ Use PPI (Proton Pump Inhibitor) ■ ◆ Risk benefit between bleeding and ischemia ◆ DAPT score can be helpful Key Points Regarding DAPT (3/3) Updates in Acute Coronary Syndromes TOPICS Timing of Non-Cardiac Surgery: ■ Dual Antiplatelet Therapy (DAPT) ■ ◆ Ideally > 1 month after BMS , 6 months after DES ◆ Choice and Dosing ◆ Continue Aspirin if possible ◆ Hold : ◆ Duration ✦ Ticagrelor 3 days prior to surgery ◆ Triple Therapy ✦ Clopidogrel 5 days prior to surgery ◆ Cessation for Surgery ✦ Prasugrel 7 days prior to surgery ◆ Management in the Bleeding Patient ■ Stopping for Bleeding ■ ACS Performance Metrics in 2017 ◆ Consider severity of bleeding ◆ Continue DAPT, SAPT when possible if indicated ◆ 9
◆ 10/21/17 2017 ACS Performance Measures (TOP 10) Arrival Hospitalization Discharge ■ Aspirin ■ Evaluation of LVEF ■ Aspirin ■ Troponin ■ ACEi or ARB ■ P2Y12 Inhibitor within 6 hours ■ Non invasive stress test ■ Beta Blocker (if no cath) ■ Statin (High intensity) ■ Cardiac Rehab 2017 ACS Quality Measures What Have We Learned? Metrics that may be useful for local quality improvement but are not yet ◆ appropriate for public reporting or pay for performance programs. New measures are initially evaluated for potential inclusion as ◆ Dual Antiplatelet Therapy performance measures. Choice of Antiplatelet Agents ■ Duration of DAPT after ACS and PCI ■ An Approach to Anticoagulation and DAPT ■ Timing of Non Cardiac Surgery after PCI ■ Management of DAPT for patients with bleeding ■ Performance Measures for ACS in 2017 Medications on discharge (Aspirin, P2Y12, Beta Blocker, ACEi) ■ Assessment of LV function Avoid Using NSAIDS for pain control! ■ ■ Referral to Cardiac Rehab Don’t prescribe prasugrel for patients with a history of ■ ■ Stroke/TIA Use Aspirin 81 mg daily with Ticagrelor ■ ◆ 10
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