glen j. kowalchuk, md, facc, fasci - atrium health · 2017. 7. 20. · mi ecabg mace bleeding...
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S a n g e r H e a r t & Va s c u l a r I n s t i t u t e S y m p o s i u m 2 0 1 5
Cardiovascular Update For Primary Care Physicians
Glen J. Kowalchuk, MD, FACC, FASCI
My patient with a stent on dual antiplatelet therapyneeds surgery: interventional cardiologist please
advise
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Sanger Heart & Vascular Institute Symposium 2015
Disclosures
• Speakers bureau for: – Lilly – Daiichi Sankyo– Pfizer– Bristol Myers
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Sanger Heart & Vascular Institute Symposium 2015
Effect of Recent Stenting on Surgical Outcomes
• 40 Patients with surgery 1-39 days after BMS– 8 of 25 patients within 2 weeks of stenting died ( 6 MI’s , 2 bleeds)– 0 of 15 patients died with surgery 15-39 days after stenting
• 207 patients undergoing surgery within 2 months after BMS– 8 of 207 patients died, suffered MI, or experienced stent thrombosis– All events occurred in the first 6 weeks– No events occurred in those from week 6 to week 8
J Am Coll Cardiol. 2000;35:1288‐1294
J Am Coll Cardiol. 2003;42:234‐240
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Sanger Heart & Vascular Institute Symposium 2015
Incremental Risk of Non-cardiac Surgery on Adverse Cardiac Events Following Coronary Stenting
J Am Coll Cardiol. 2014;64(25):2730‐2739
Retrospective cohort analysis of 20,590 surgical vs. 41,180 nonsurgical patients 2000‐2010
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Sanger Heart & Vascular Institute Symposium 2015
Stent Thrombosis
Pre‐Stent Post Stent 33 days Post Stent
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Sanger Heart & Vascular Institute Symposium 2015
In Hospital Stent Outcomes with Aggressive Anticoagulation18
0.6
5
12.5
0
15
0.6
5
8.5
02468
101214161820
ASA/dipyridamole ASA/dipyridamole/warfarin
SATMIECABGMACEBleeding
Schatz, et al. Circ 1991;83:148
n=39 n=174
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Sanger Heart & Vascular Institute Symposium 2015
Stent Anticoagulation and Restenosis Study
N Engl J Med 1998;339:1665‐71
DES: Early Discontinuation of Anti-platelet Therapy is the Strongest Risk Factor for ST
Unstable angina
Thrombus Diabetes Unprotected left main
Bifurcation Renal failure
Prior brachy Rx
Premature antiplateletdiscont’d
Inci
denc
e (%
)
Iakovou et al. JAMA. 2005;293:2126.
N=2229 Overall stent thrombosis = 1.3%
HR 90Case fatality rate: 45%
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Sanger Heart & Vascular Institute Symposium 2015
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Sanger Heart & Vascular Institute Symposium 2015
Surgical bleeding with ClopidogrelIn non-cardiac surgery, comparing patients taking clopidogrel and aspirin within 6 days of surgery (n=28) vs. those who stopped >6 days prior to surgery (n=22) experienced:
– More bleeding requiring transfusions 21.4% vs. 9.5%– Similar hospital stays, ICU stays, and mortality
104 patients receiving clopidogrel who underwent abdominal operations between March 2003 and March 2009. Patients were grouped by last clopidogrel use: group A (<7 days) and group B (≥7 days).
The Am Surg.74;8, August 2008:721‐725(5) Arch Surg. 2011;146(3):334-339
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Sanger Heart & Vascular Institute Symposium 2015
Effect of Thienopyridine Use on Stent Thrombosis Following DES Implant
3021 patients after implant of 2853 SES or 2536 PES April 2002 to December 2004
Overall ST rate 1.9%
TCT 2006
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Sanger Heart & Vascular Institute Symposium 2015
SPIRIT IV 1‐year results, Gregg Stone, TCT 2009
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Sanger Heart & Vascular Institute Symposium 2015
5054 “real world” patients at 162 US sites‐ 37.5% ACS ‐ 40.8% multi‐vessel‐ 35.6% DM‐ 18.1% AMI‐ 11.1% CKD
J Am Coll Cardiol Intv 2011;4:1298–309
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Sanger Heart & Vascular Institute Symposium 2015
Factors to Consider in Patients Undergoing Surgery Post Stent Implant
• Elective vs. urgent surgery• Complexity of surgery and risk of bleeding• Indications for initial stent implant• Type of stent initially implanted• Timing since stent implant
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Sanger Heart & Vascular Institute Symposium 2015
Recommendations
• Delay surgery at least 6 months, if possible
• Continue DAPT or at least aspirin throughout the peri-operative period if early surgery is necessary
• Minimize the clopidogrel, prasugrel, or ticagrelor free interval as much as possible
• Communicate with surgical colleagues
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