Fibril.lació auricular i stents a la Síndrome Coronària Aguda

Antonia Sambola MD, PhD, FESCUnitat Cures agudes cardiològiquesHospital universitari Vall d’Hebron

SCA i anticoagulants d’acció directa. Qüestions pràctiques

High risk bleeding…. NO longer contraindication for DES?

Ariotti S, JACC Cardiovasc Interv 2016;9:426–436.

RCT N= 828 patients

- indication to oral anticoagulants 12%- Patients with AF ???

ZEUS TRIAL

N=828

Philip Urban, Alexandre Abizaid, Ian T. Meredith, Stuart J. Pocock, Didier Carrié, Christoph Naber,

John Gregson, Samantha Greene, Hans Peter Stolland Marie-Claude Morice for the LEADERS FREE Investigators

Biolimus-Coated vs. Bare-Metal Coronary Stents in High Bleeding Risk Patients

Valgimigli M, J Am Coll Cardiol 2015;65:805–815.

N=2466

Summary

•The last European guidelines on myocardial revascularization recommend using DES in any PCI, irrespective of concomitant anticoagulant therapy.

•There is limited evidence suporting this strategy.

• it is difficult to extrapolate the results of these trials the full population of patients with AF.

Anticoagulants acció directa post-IAM. Associats a doble

antiagregació?

SCA i anticoagulants d’acció directa. Qüestions pràctiques

ANTITROMBOTICOS EN PACIENTES CON FA Y SCA

1.Rapsomaniki et al. Eur Heart J Qual Care Clin Outcomes 2016: 2; 172–1832.Wolf P et al, Stroke 1991;21:983–988; 3 Lamberts M et al Circ lation 2012 126 1185 1193

Tasa

s de

inci

denc

ia b

ruta

(e

vent

os p

or 1

00pe

rson

as-a

ño-±

EE)

Muerte por causas CV más IM más ictus isquémico

Hemorragia mortal y no mortal

0

10

20

30

40Triple terapia (AVK más AAS másclopidogrel)AVK más antiagregante plaquetario

DAP (AAS más clopidogrel)

La triple terapia con AVK reduce los eventos tromboembólicos, pero dobla el riesgo hemorrágico en pacientes con FA+ICP

Registro danés (2000-2009; N = 11 480 pacientes)

Lamberts M et al, Circulation 2012;126:1185–1193

Triple or dual therapy?Duration dual or triple therapy?

VKA or DOAC?

Which dose of DOAC?

Which DOAC?

Dose of anticoagulation in combination withantiplatelet agents

Lower rates of ISTH major or CRNM bleeding with dabigatran vs warfarin in patients with or without ACS (50% ACS)

Baseline characteristics were similar in patients with or without ACSACS, acute coronary syndrome; D, dabigatran; W, warfarin. Oldgren et al. Presented at AHA 2017

Patie

nts w

ith o

utco

me

even

t (%

)

14.7

27.8

D 110 mgdual therapy

(n=509)

W tripletherapy(n=475)

HR: 0.47 (95% CI: 0.35–0.63)

ACS

16,1

26,1

D 110 mgdual therapy

(n=472)

W tripletherapy(n=505)

Non-ACS

HR: 0.57 (95% CI: 0.43–0.76)

P for interaction = 0.34

20,5

27.1

0

5

10

15

20

25

30

35

D 150 mgdual therapy

(n=391)

W tripletherapy(n=369)

ACS Non-ACSP for interaction = 0.57

19,9

24,4

D 150 mgdual therapy

(n=372)

W tripletherapy(n=394)

HR: 0.67 (95% CI: 0.50–0.90)

HR: 0.76 (95% CI: 0.56–1.03)

Results were consistent for ISTH and TIMI classifications of major bleeding

(see Appendix I)

No significant interaction between treatment and patients with or without ACS in primary safety endpoint

22

Similar efficacy with dabigatran vs warfarin in patients with or without ACS (50% ACS)

15 mg

What type of antiplatelet agent?

Dual antiplatelet therapy choice in patients withindication for oral anticoagulation

Ticagrelor*†

(N=327)Clopidogrel†‡

(N=2398)

Indication for PCI, n (%)Stable angina/positive stress test

78 (23.9) 1104 (46.0)

Acute coronary syndrome

240 (73.4) 1135 (47.3)

Staged procedure or other¶ 70 (21.4) 562 (23.4)

DAPT trial complexity factors, n (%)

No clinical/proceduralfactor

67 (20.5) 941 (39.2)

Clinical complexity factor

193 (59.0) 981 (40.9)

Procedural complexity factor

16 (4.9) 254 (10.6)

Both clinical and procedural complexity factors

51 (15.6) 222 (9.3)

Sólo 16% con Ticagrelor

PIONEER-PCI REDUAL-PCI

Sólo 13% con Ticagrelor

ESC Guidelines 2017 and consensus documentEHRA2018

Valmigli ESC update antiplatelet EHJ 2017 Lip et al Europace 2018; Neumann ESC Guidelines myocardial revasc. EHJ 2018 Steffel EHRA consensus 2018

• Apixaban 5mg b.i.d or apixaban 2.5 mg b.i.d. if at least two of the following: age>_80 years, body weight <_60 kg or serum creatinine level >_1.5 mg/dL (133 lmol/l

• Dabigatran 110 mg b.i.d.; Edoxaban 60 mg q.d. or edoxaban 30 mg q.d. if any of the following: creatinine clearance (CrCl) of 30–50 mL/min, body weight <_60 kg, concomitant use of verapamil or quinidine or dronedarone;

• Rivaroxaban 20 mg q.d. or rivaroxaban 15 mg q.d. if CrCl 30–49 mL/min.

REGISTRATION• Early fee deadline: 20 December• Late fee deadline: 04 February

Acute Cardiovascular Care 2019 2-4 March 2019, Malaga, Spain

Programme highlights

Discounts available for ACCA members. Choose your membership.

www.escardio.org/acutecvd #AcuteCVD2019

• 3i: Innovative, interactive, and inspiring education

• Test, explain, and translate 2018 ESC Guidelines

• Case-based and how-to sessions

Característica Grupo 115 mg de

rivaroxaban1 v/d + un

antiagregante plaquetario (N = 709)

Grupo 22,5 mg de

rivaroxaban2 v/d + DAP

(N = 709)

Grupo 3AVK + DAP(N = 706)

Inhibidor de P2Y12 en el periodo basal, n (%)

Clopidogrel 660 (93,1) 664 (93,7) 680 (96,3)

Prasugrel 12 (1,7) 11 (1,6) 5 (0,7)

Ticagrelor 37 (5,2) 34 (4,8) 21 (3,0)

Urgencia de la revascularización, n (%)

Programada 428 (60,4) 430 (60,6) 449 (63,6)

Urgente 281 (39,6) 279 (39,4) 257 (36,4)

Tipo de acontecimiento inicial, n (%)

IMSEST 130 (18,5) 129 (18,4) 123 (17,8)

IMEST 86 (12,3) 97 (13,8) 74 (10,7)

Angina inestable 145 (20,7) 148 (21,1) 164 (23,7)

Gibson CM et al, New Engl J Med 2016; doi: 10.1056/NEJMoa1611594]

COMPARISON WITH EXPERT CONSENSUS NORTH AMERICAN PERSPECTIVE