dapt should be prolonged in patients with acute coronary ... · death myocardial 0.95infarction...
TRANSCRIPT
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DAPT should be prolonged in patients with acute coronary syndrome ?
João Morais
Head of Cardiology Division
Leiria Hospital Centre
Chairman WG Thrombosis
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João Morais Honoraria received from Astra Zeneca and Merck Sharp & Dhome Consulting activities and invited speaker National and international levels
Disclosures related with the current topic
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DAPT
Antithrombin
Aspirin +
ticagrelor or prasugrel
UFH or LMWH/fondaparinux or bivalirudin
+
In hospital 12 months DAPT, dual antiplatelet therapy; LMWH, low molecular weight heparin; UFH, unfractionated heparin
Antithrombotic environment in patients with ACS
∕∕
P2Y12inhib
???? ????
Clopidogrel
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Patient oriented strategy
Stent oriented strategy
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DAPT post ACS Rationale for 12 months of treatment duration
Total death / AMI at 12 months Event rate
Revascularization (+) 5.2% Revascularization (-) 9.0%
Cu
mu
lati
ve s
urv
ival
(%
)
Revasc (+)
Revasc (-) Discharge
Morais J et al Unpublished data
Single centre (n=965)
0 3 6 9 12
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CURE PLATO
TRITON
DAPT post ACS Rationale for 12 months of treatment duration
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?
? ? ? ? ? ?
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Stent oriented strategy
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Time duration can be shorten ?
Capodanno D, Circulation. 2013;128:2785-2798
DAPT post stent implantation
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Death Myocardial Infarction Stent Thrombosis Cerebrovascular Accident TIMI Major Bleeding
Odds Ration M-H Random 95% CI 1.15 |0.85, 1.54] 0.95 [0.66, 1.36] 0.88 [0.43, 1.81] 1.51 [0.92, 2.47] 2.64 [1.31, 5.30]
Extended Better Control Better
Clinical Impact of Extended DAPT after PCI A metanalysis of Randomized trials (n=8231)
N Engl J Med 2010;362:1374–1382 Circulation 2012;125:2015–2026 Circulation 2012;125:505–513. J Am Coll Cardiol. 2012 Oct 9;60(15):1340-8.
Cassese et al Eur Heart Journal 2012; 33: 3078-3087
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DAPT post stent implantation Stent thrombosis – new generation of stents
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Drug eluted stents 1st vs 2nd generation
Giustino G, et al. J Am Coll Cardiol 2015;65:1298–310
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Patient oriented strategy
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Outcomes in patients with atherosclerosis
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0,6%
3,8%
8,9%
0,6%
3,3% 2,8%
7,8%
2,6%
7,2%
2,6%
7,2%
2,3%
Morte EAM Revasc. AVCAll death AMI Revasc Stroke
João Morais, 2016 to be published
Single centre N=965 12 months f-up
Global event rate 14,1%
Unstable angina
STEMI
NSTEMI
4,5% 2,9% 7,7% 2,1%
Outcomes in post ACS patients
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PROSPECT: MACE M
AC
E (%
)
Time in Years 0 1 2 3
All Culprit lesion (CL) related Non culprit lesion (NCL) related Indeterminate
0
5
10
15
20
25
Number at risk
ALL 697 557 506 480
CL related 697 590 543 518
NCL related 697 595 553 521
Indeterminate 697 634 604 583
12.9%
20.4%
11.6%
2.7%
13.2%
7.9%
6.4%
0.9%
18.1%
11.4%
9.4%
1.9%
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Extended DAPT
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HR (95% CI) ≤ 1 Year:
0.99 (0.84, 1.16)
HR (95% CI) > 1 Year:
0.72 (0.54, 0.97)
Primary Efficacy Endpoint to 30 Months (Age < 75 years)
HR (95% CI):
0.91 (0.79, 1.05)
P = 0.21
Interaction P = 0.07
Prasugrel vs. Clopidogrel for Acute
Coronary Syndromes Patients Managed
without Revascularization
the TRILOGY ACS trial
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Background – 1° Efficacy Evaluation Overall Population
CV Death, MI, or Stroke
9.3%
10.5%
Hazard Ratio 0.87
p < 0.001
N = 26449
Mean f/u: 2.5 years Placebo
Vorapaxar
GUSTO Mod/Sev at 3 yrs
4.2 v. 2.5%, HR 1.66, p<0.001
Morrow et al. N Engl J Med 2012
ClinicalTrials.gov NCT00526474c
0%
2%
4%
6%
8%
10%
12%
0 60 120 180 240 300 360 420 480 540 600 660 720 780 840 900 960 1020 1080
Ev
en
t R
ate
(%
)
Days since randomization
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Extended DAPT Udell’s meta-analysis
European Heart Journal doi:10.1093/eurheartj/ehv443
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?
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Final remarks - I
Appropriate patient selection is the key to handle the delicate balance between preventing thrombosis and
provoking bleeding
Patients with an established history of ACS and / or stent implantation may benefit of DAPT
prolongation. The exact time duration is unknown
Patient oriented approach should be preferred over a more simplistic way focusing only on the stent
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Final remarks - II
Individual characteristics Thrombotic risk
Bleeding risk Associated co-factors
DAPT score
Stent characteristics Type of stent
(nr, length, location, diameter, overlap, dissection)
Coronary anatomy
Individualized therapy should be based on
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Many thanks
João Morais
Head of Cardiology Division
Leiria Hospital Centre
Chairman WG Thrombosis