6/18/2018 Disclosures Updates in Interventional Cardiology and Guidelines No Conflicts of Interest Krishan Soni, MD, MBA, FACC Assistant Professor of Medicine Division of Cardiology Krishan.soni@ucsf.edu Advances in Internal Medicine 2018 Updates in Interventional Cardiology Updates in Interventional Cardiology and Guidelines and Guidelines TOPICS Dual Antiplatelet Therapy (DAPT) Major Society Guideline Choice and Dosing Updates 2016-2017 Duration Interruption for Surgery Clinical Trials Published Triple Therapy (Anticoagulation+DAPT) 2016-2017 Quality Care after Myocardial Infarction 1
6/18/2018 Objectives Strength of Guideline Recommendations Recognize important differences between oral P2Y 12 inhibitors Understand differences in DAPT duration after PCI based on use of bare metal / drug eluting stent based on stable or acute presentation Be aware of factors influencing risk and benefit on deciding duration of antiplatelet therapy Understand timing of non-cardiac surgery after coronary stent placement Know options for managing triple therapy Be aware of new quality metrics when caring for patients after myocardial infarction Acronyms Updates in Interventional Cardiology and Guidelines ACS : Acute Coronary Syndrome BMS: Bare Metal Stent TOPICS CAD : Coronary Artery Disease Dual Antiplatelet Therapy (DAPT) CABG: Coronary Artery Bypass Graft Surgery Choice and Dosing DAPT : Dual Antiplatelet Therapy Duration DES: Drug Eluting Stent Interruption for Surgery PCI : Percutaneous Coronary Intervention Triple Therapy PPI: Proton Pump Inhibitor SIHD : Stable Ischemic Heart Disease Quality Care after Myocardial Infarction VKA : Vitamin K Antagonist 2
6/18/2018 Oral Antiplatelet Agents P2Y 12 Inhibitors: Mechanism of Action Aspirin Clopidogrel Prasugrel Ticagrelor Indication ACS ACS Post PCI ACS Post PCI Post PCI Post PCI Stroke Stroke PVD PVD Dose Load 325 mg 300-600 mg 60 mg 180 mg Maintenance 81 mg 75 mg 10 mg 90 mg DAILY DAILY DAILY BID 2 nd gen 2 nd gen Class NSAID CTPT thienopyridine thienopyridine (PRODRUG) (PRODRUG) Mechanism IRREVERSIBLE IRREVERSIBLE IRREVERSIBLE REVERSIBLE COX 1 P2Y 12 P2Y 12 P2Y 12 Peak Effect 1-3 hours 6 hours 4 hours 2 hours CYP NA 2C19 3A4 3A4/5 Metabolism Schomig A; N Eng J Med 2009 Aspirin dosing in patients with CAD Higher doses of aspirin are associated with bleeding and no increased anti-ischemic benefit When used with ticagrelor, aspirin doses of >100 mg are contraindicated. 3
6/18/2018 According to US Guidelines, how long Duration of dual antiplatelet therapy should patients be on Dual Antiplatelet (DAPT) Therapy (DAPT) after percutaneous Duration of DAPT depends on: coronary intervention (PCI) with a Drug Underlying condition Eluting Stent? 59% Treatment provided A. 3 months B. 6 months C. 12 months D. It depends on the 17% 14% 10% indication for PCI E. Call a cardiology 0% consult s s s h h h t l t t t . u Stable Ischemic Heart Acute Coronary Syndromes n n n . . s o o o t n a m m m o c i c 3 6 d 2 y 1 n Disease (SIHD) (ACS) g i o e l h o t d i n r o a c s d a n l e a l p C e d t I Duration of dual antiplatelet therapy Duration of dual antiplatelet therapy (DAPT) in patients with ACS (DAPT) in patients with SIHD Stable Ischemic Heart Acute Coronary Disease (SIHD) Syndromes (ACS) Stopping early at 3 months ACS = 1 year PCI with Bare PCI with Stopping Metal Drug early Stent Eluting at 6 months (BMS) Stent (DES) 1 MONTH 6 MONTHS 4
6/18/2018 When should DAPT therapy be The DAPT score can guide risk / benefit continued for LONGER duration? of longer therapy Risk of Ischemia Risk of Bleeding Score ≥ 2 Favorable benefit/risk For prolonged DAPT Score <2 NOT Favorable benefit/risk For prolonged DAPT Which P2Y 12 agent should I Other pearls regarding P2Y 12 inhibitors recommend? Ticagrelor can cause dyspnea (14%) and bradycardia (6%) Prasugrel may be less effective in patients < 60 kg and > 75 years of age For Medically Reasonable to choose should not be given until after invasive Managed ACS Ticagrelor over Clopidogrel angiography (Class III) do not give to patients with a history of For ACS with Reasonable to choose Ticagrelor TIA or stroke (Class III) PCI or Prasugrel over Clopidogrel 5
6/18/2018 You receive a message from the Ticagrelor is not covered by the patient’s patient’s pharmacy insurance. What do you do? 44% 44% Your patient was admitted with an NSTEMI. Your friendly interventional cardiologist placed a drug eluting stent. The A. Switch to clopidogrel 75 patient was started on ticagrelor 90 mg PO BID. mg daily B. Switch to clopidogrel, “Ticagrelor is not covered load with 600 mg, then by this patient’s insurance and he wont be able to 75 mg daily 9% receive the medication at 3% C. Make a plea to the home unless he pays out insurance company of pocket” . D. Tell your patient “It’s . . . . . . . r . . . o 5 l r u w 7 , l s e l n s e r ’ g i t What do you do? r e worth paying for” g o I h “ o d t t d i n p i o e p o t i o t c l a l a c e p o l o t p r t h u a h c o e c t y t i k w w i a l e l S M S T Switching between oral P2Y 12 inhibitors Switching between oral P2Y 12 inhibitors acute settings (ACS, recent PCI) chronic settings Always reload in the acute setting (ESC IIb recommendation) Reload only if switching from ticagrelor to another agent 6
6/18/2018 Updates in Interventional Cardiology 65 yo man underwent PCI with a drug eluting stent to the Left Anterior Descending artery 2 months ago and Guidelines for stable angina. He now has severe knee osteoarthritis and is asking you when he can have TOPICS surgery. How long after his stent should he wait? Dual Antiplatelet Therapy (DAPT) 59% Choice and Dosing A. 1 month B. 3 months Duration C. 6 months Interruption for Surgery 21% D. 12 months 17% Triple Therapy E. He should be managed 3% 0% medically indefinitely Quality Care after Myocardial Infarction 1 month 3 months 6 months 12 months He should be managed m... Perioperative management and timing of Perioperative management and timing of non cardiac surgery non cardiac surgery Wait at least 3 months and preferably 6 months after PCI During perioperative period: with DES Continue aspirin if possible Restart P2Y 12 as soon as possible Wait 30 days after PCI with BMS 7
6/18/2018 Perioperative management and timing of Key points regarding DAPT (2/2) non cardiac surgery Dose of Aspirin for all patients is 81 mg daily How long before surgery should DAPT be stopped? CONTINUE ASPIRIN if possible! Duration of DAPT: ACS Patients: 1 YEAR for ALL (with/without stent) SIHD (Stable Ischemic Heart Disease) Patients: Drug Eluting Stent (DES): 6 MONTHS Bare Metal Stent (BMS): 1 MONTH Stopping Early: DAPT could be stopped 3 months after DES (drug eluting stent) for high bleeding risk patients Longer Therapy: Risk benefit between bleeding and ischemia Ticagrelor 3 days prior to surgery DAPT score can be helpful Clopidogrel 5 days prior to surgery Prasugrel 7 days prior to surgery Key points regarding DAPT (2/2) Updates in Interventional Cardiology and Guidelines Choice of Agents: Ticagrelor reasonable over Clopidogrel for ACS TOPICS Ticagrelor or Prasugrel are reasonable over Clopidogrel after PCI for ACS Dual Antiplatelet Therapy (DAPT) Do NOT USE Prasugrel if history of stroke or TIA Choice and Dosing When switching agents, reload if ACS or switching from Ticagrelor Duration Interruption for Surgery Timing of Non-Cardiac Surgery: Ideally > 1 month after BMS , 6 months after DES Triple Therapy Continue Aspirin if possible Hold : Quality Care after Myocardial Infarction Ticagrelor 3 days prior to surgery Clopidogrel 5 days prior to surgery Prasugrel 7 days prior to surgery 8
Recommend
More recommend
