clinical experience with novel antiplatelet therapy …...clinical experience with novel...
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Clinical experience with novel antiplatelet therapy ticagrelor:which patients benefit the most?
Maja Strozzi, Marko Noč, Robert Bernat
3rd DUBROVNIK CARDIOLOGY HIGHLIGHTS 2013, 27.09.2013.
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All presentations are made on the
request of AstraZeneca, according to
valid legislative. All presentations are
nonpromotional.
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Ticagrelor – who
benefits most ?
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The concept ...
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5
The topics
Guidelines
Evidence on ticagrelor
Evidence analysis
Subgroups who benefit most
Ticagrelor – a drug for the widest
spectrum of ACS ?
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Guidelines
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ACCF/AHA NSTEACS 2012
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ACCF/AHA STEMI 2013
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9
ESC Myocardial Revascularization 2010
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10
ESC NSTEACS 2011
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11
ESC STEMI 2012
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•Prasugrel – TRITON-TIMI 38* (13.608)
•Ticagrelor – PLATO** (18.624)
The evidence:
* Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel
versus clopidogrel in patients with acute coronary
syndromes. N Engl J Med 2007;357:2001-15
** Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus
clopidogrel in patients with acute coronary syndromes. N
Engl J Med 2009;361:1045-57.
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Evidence analysis
prasugrel ticagrelor
patient profile
older (>75y)
fragile (<60kg)
prior stroke/TIA
adverse effects
dyspnea
bradycardia
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Subgroup analysis
prasugrel ticagrelor
efficacy
CV death
ACS treatment
PCI
CABG
medical
?
?
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Who will benefit most ?
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ACS Case
• F, 70y
• hypertension, DM, dyslipidemia, smoker
• 1.2.2013. STEMI inf.
• agregometry (patient included in a study), randomized to
standard clopidogrel dose. Results known later: clopidogrel
hypo reactor
TIMI score 4, mort. 7,6%GRACE score 141, mort.17%
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STEMI 2012: antithrombotic therapy
In acute phase Ticagrelor without limitations (clopidogrel only if new ADP-
receptor blocker are not available)
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Tica-grelor
HZZO
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Acute STEMI
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PCI result
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STEMI 2012: antithrombotic therapy
In the follow up recommended over clopidogrel
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IST
• referred for CABG, surgery delayed (DAPT). Finally
patient refused surgery!
• 11.2.2013. re-STEMI, IST, cardiogenic shock, AV block
III, VT, mechanic ventilation, TIA?
• rePCI, GP 2b/3a, ECG normalization in inf. leads
TIMI score 10, mort. 38,7%GRACE score 215, mort. 80%
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IST
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Case 2 – How would you treat ?
m, 53 y, anterior STEMI
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Case 2 – How did I treat ?
1 manual aspiration, 3 wires & 2 stents later...
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Case 3 – How would you treat ?
m, 71 y, s/p CABG, NSTEACS
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Case 3 – How would you treat ?
on day 6 – subac. thrombosis...
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Case 3 – How did we treat ?
on day 6 – subac. thrombosis, aspiration only...
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PLATO study: In stent thrombosis
Patients with intent for invasive treatment
Ticagrelor (n=6732)
Clopidogrel (n=6676)
HR for ticagrelor (95% CI)
P value
Stent thrombosis, n (%)
Definite 71 (1.3) 106 (1.9)0.67 (0.50-
0.91)0.0091
Probable + Definite 118 (2.1) 158 (2.8)0.75 (0.59-
0.95)0.0167
Possible + Probable + Definite 155 (2.8) 202 (3.6)
0.77 (0.62-
0.95)0.0131
Wallentin L, et al. N Engl J Med. 2009;361:1045-1057.
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Second IST
• 20.3.2013. re-re-STEMI inf
• re-re-PCI RCA, good clinical recovery, EHO – EF 40%
• stable angina III st
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Second IST
high risk ACS, potential CABG, clopidogrel hypo reactor, repeat in
stent thrombosis
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Stable angina 2013: antithrombotic therapy
Ticagrelor should or may be considered in some stable patients
after PCI
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PLATO outcomes (early and late period)
Wallentin L. Presented at ECS congress 2009
MACE reduction benefite increase by time.
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PLATO study
• Significant reduction of
cardiovascular death (4,0 to
5,1% in 12 months)
• Treating 1000 patients with
ticagrelor, 14 lives can be saved
Wallentin L, et al. N Engl J Med. 2009;361:1045-1057
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My questions after PLATO
Study has shown superiority of the new drug.
Considering the price, can we give it to all ACS
patients?
Probably not
Can we identify a group of patients who would benefit
most from ticagrelor therapy?
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Subgroup analysis
Wallentin L et al N Engl J med. 2009,381:1045-57
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ACS patients with diabetes
James S et al. Eur Heart J. 2010 Dec;31(24):3006-16.
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ACS patients with diabetes
James S et al. Eur Heart J. 2010 Dec;31(24):3006-16.
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Who would benefit most?
Patients with ACS and planed early invasive strategy (less than
2 hours) because fast and consistent blockade of P2Y12
receptors
PCI patients with high potential for thrombotic events because
of significant reduction of in stent thrombosis (large thrombus
burden, suboptimal PCI result, slow TIMI flow, long stent
segment etc.) or clinical characteristic like diabetes, renal failure
etc.
Patients with stent thrombosis and documented clopidogrel
resistance.
It would be reasonable for all ACS because of significant
mortality reduction in 1 year follow up
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Ticagrelor for all patients with ACS?
It would be difficult to achieve that, due to
current economic situation
Individual patient selection, what I prefer,
would be difficult to apply
We proposed Ticagrelor in all patient
undergoing urgent PCI for acute myocardial
infarction included in the "Croatian PCI
network"
Patients with in stent thrombosis and known
clopidogrel resistance are implied
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Thank you.