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

Angioplastie élective à haut risque thrombotique

Philip Urban Hôpital de la Tour Genève

DAPT intensity & duration

Patient Lesion & Procedure Stent

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…

ISR SVG

PRODIGY, OPTIMIZE, RESET, EXCELLENT, SECURITY and ITALIC included only native coronary de novo lesions

J Am Coll Cardiol 2014;63:506–12 P=0.034 16.7% 8.3%

• 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

PCI-

7.9 7.9 11.7 11.7 2154 2154 No Diabetes No Diabetes 12.9 12.9 16.5 16.5 504 504 Diabetes Diabetes 13.5 13.5 12.0 12.0 8.9 8.9 12.3 12.3 2114 2114 PCI > 72 h Rand PCI > 72 h Rand 8.5 8.5 544 544 PCI PCI £ 72 h Rand 72 h Rand 8.3 8.3 1730 1730 PCI in 1st Hosp. PCI in 1st Hosp. 13.8 13.8 9.8 9.8 928 928 PCI After 1 PCI After 1st

st Hosp.

Hosp. 21.7 21.7 9.6 9.6 332 332 H/O CABG H/O CABG 11.2 11.2 8.7 8.7 2326 2326 No H/O CABG No H/O CABG Clopid Clopid Plac Plac 2N 2N

Clopidogrel Clopidogrel better better Placebo better Placebo better

0.2 1.2 1.0 0.8 0.6 0.4 Relative Risk Relative Risk

CV Death or MI from CV Death or MI from Randomization to End Randomization to End

Mehta SR et al. Lancet 2001:358:527-33

2658 NSTEMI patients

4 weeks Aspirin + Clopidogrel post PCI only vs. Preloading and long term DAPT Primary EP: CV death, MI or TVR < 30 days

Effect of pre-treatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study

J Am Coll Cardiol 2012;60:2357–63

“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” 411 patients event-free at the time of clopidogrel cessation

The DAPT Score

13

0% 5% 10% 15% 20% 25% 30%

• 2 -1 0 1 2 3 4 5 6 7 8 9 10

Percentage of Patients DAPT Score

Variable Points Patient Characteristic Age ≥ 75

• 2

65 - <75

• 1

< 65 Diabetes Mellitus 1 Current Cigarette Smoker 1 Prior PCI or Prior MI 1 CHF or LVEF < 30% 2 Index Procedure Characteristic MI at Presentation 1 Vein Graft PCI 2 Stent Diameter < 3mm 1

Distribution of DAPT Scores among all randomized subjects in the DAPT Study

Standard DAPT (12 months) Extended DAPT

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

• utcomes or potentially associated with higher risk
• f 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.

High risk

• Age > 75
• Renal insufficiency (< 60 ml/min)
• Diabetes Mellitus
• BMI >30
• History of ACS in the past 12 months
• LVEF < 40% and/or CHF
• Multivessel disease
• Multiple stents needed
• Total stent length envisioned > 30mm,
• Left main stenting
• Bifurcation stenting
• ACC/AHA type B2 or C lesion
• Stenting of venous or arterial graft

Primary endpoint: MI or myocardial damage at 48h or discharge Secondary endpoint: BARC 3-5 bleeding at 48h

• r discharge

1900 elective high risk PCI candidates

• n aspirin

Ticagrelor pre-PCI loading + 30 days Clopidogrel pre-PCI loading + 30 days

bleeding thrombosis

A delicate balance

Primary Endpoints and Major Bleeding at 1 Year

Urban P et al. N Engl J Med 2015;373:2038-47

Efficacy (cd-TLR) Safety (cardiac death, MI, ST)

90 180 270 390 Cumulative Percentage with Event 3 6 9 12 Days

9.8% 5.1%

p for superiority < 0.001 HR 0.50, (95% CI = 0.37‒0.69) %

12.9%

BMS DCS

90 180 270 390 3 6 9 12 Days

9.4%

HR 0.71, (95% CI = 0.56‒0.91) p < 0.0001 for non-inferiority p = 0.005 for superiority 15 %

Bleeding (BARC 3-5)

%

7.3% 7.2%

2466 HBR patients randomised to BA-9 DCS or BMS One month DAPT only for all

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) 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%) Bleeding risk > 2x thrombotic risk N=210 (9.7%)

Integer score < -5 Integer score > +5

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

Thank you