j berland clinique saint hilaire rouen -...
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J BERLAND
Clinique Saint Hilaire
ROUEN
DUREE de la BITHERAPIE
dans les ETUDES LEADERS
LEADERS ‘all-comers’ Trial Design
1o endpoint: MACE: Cardiac death, MI, clinically-indicated TVR (9 mo)
2o endpoints: Death, CV death, MI, TLR, TVR
Stent thrombosis according to ARC
Angiographic study: In-stent % diameter stenosis (9 mo)
Late loss, binary restenosis
DAPT recommended for 12 months
BioMatrix Flex™ (BES)*
N=850
Cypher® Select™ (SES)
N=850
Stable and ACS Patients Undergoing PCI
N=1700 Patients
10 European centers
1:3 Randomisation
Clinical F/U
N=640
Angio F/U
N=210
Clinical F/U
N=640
Angio F/U
N=210
Assessor-blind
1:1 Randomisation
Antiplatelet Agent Utilization
BES SES P value*
Aspirin
At 1 year 786/810 (97%) 770/801 (96%) 0.32
At 2 years 749/789 (95%) 733/777 (94%) 0.60
At 3 years 714/757 (94%) 709/748 (95%) 0.69
At 4 years 694/745 (93%) 681/730 (93%) 0.93
Clopidrogel or ticlopidine
At 1 year 552/810 (68%) 534/801 (67%) 0.53
At 2 years 185/789 (23%) 189/774 (24%) 0.68
At 3 years 148/757 (20%) 153/749 (20%) 0.67
At 4 years 119/745 (16%) 135/730 (18%) 0.21
Dual antiplatelet therapy
At 1 year 536/810 (66%) 513/801 (64%) 0.37
At 2 years 171/789 (22%) 168/777 (22%) 0.98
At 3 years 126/757 (17%) 133/749 (18%) 0.57
At 4 years 96/745 (13%) 111/730 (15%) 0.21
* P values for superiority
Ischinger et al., oral presentation, TCT 2011
Definite Stent Thrombosis (ARC)
0
1
2
3
4
5
6
0 6 12 18 24 30 36 42 48
%
Months
BES SES
2% 2.2% 2.2%
2.4%
2% 2.5%
2.9%
4%
Δ 0.3 Δ 0.7
Δ 1.6
3-year RR
0.78 (0.43 -1.432)
P=0.43*
2-year RR
0.90 (0.483 -1.67)
P=0.73*
4-year RR
0.62 (0.35 -1.08)
P=0.09*
1-year RR
0.99 (0.51-1.95)
P=0.98*
Number
s at risk
SES 850 817 801 787 776 759 750 730 714
BES 857 821 804 792 787 780 774 757 746
* P values for superiority
Stefanini G. et al., The Lancet, 2011
Ischinger et al., oral presentation, TCT 2011
0
1
2
3
4
5
6
%
0 6 12 18 24 30 36 42 48
Months after index PCI
0 to 1 year RR
0.99 (0.51-1.95)
P=0.98*
1 to 4 year RR
0.20 (0.06-0.67)
P=0.004*
BES
SES
857 821 804 792 787 780 774 757 746 BES
850 817 801 787 776 759 750 730 714 SES
No. at risk
2.0%
0.4%
2.0%
2.0%
P for interaction=0.017 * P values for superiority
Stefanini G. et al., The Lancet, 2011
Ischinger et al., oral presentation, TCT 2011
Definite ST
Landmark Analysis @ 1 Year
7
10857-0
00-E
N –
Rev.0
1
Effect of DAPT Discontinuation
2,2
0 0
2,9
2,4
0,4
0,0
0,5
1,0
1,5
2,0
2,5
3,0
3 Y ST in LEADERSST after DAPT d/c <12 M
ST after DAPT d/c >12 M
BES SES
%
N=0/165 N=4/169 N=2/515 N=0/540
Overall Population Patient who d/c DAPT
P = 0.12*
P = 0.24*
*P values for superiority (Fisher Exact Test)
3,5
38,3
0
10
20
30
40
50
60
BES SES
-33.1
(-61.7 to –10.3)
P<0.01
LEADERS - OCT Substudy @ 9 Months
Lesions With At Least
5% Uncovered Struts
(%)
29 Lesions 35 Lesions
BES
29 Lesions
SES
35 Lesions
Barlis P et al. Eur Heart J 2010, 31(2):165-176
RECOMMENDATIONS
EUROPEENNES 2010
ARGUMENTAIRE CONTRE UNE MAUVAISE
IDEE TOUTE FAITE: PROLONGER LE
PLAVIX SYSTEMATIQUEMENT
CLOPIDOGREL après implantation
de STENT ACTIF:
L’OPTION COURTE
J BERLAND
SAINT HILAIRE ROUEN
AHA
ACC ESC
SFC
HIGH TECH 2009
Trial Also comparing
stents
Devices DAPT duration (months)
Thrombotic events
Bleeding events
Status
DES LATE (n=2’701)
No SES, PES, ZES
12 vs. 24 No difference (card.death, MI)
No difference (TIMI maj.)
Published (NEJM 2010)
PRODIGY (n=2’013)
No BMS(25%), ZES, PES, EES
6 vs. 24 No difference (death,MI,CVA)
6 mth better (BARC)
Published (Circulation 2012)
RESET (n=2’117) Yes E-ZES vs. SES, EES, ZES
3 (E-ZES) vs.12
(other DES)
No difference (death,MI,ST)
No difference Published (JACC 2012)
EXCELLENT (n=1’443)
Yes EES & SES 6 vs. 12 No difference (TVF)
No difference (TIMI maj.)
Published (Circulation 2012)
DAPT (n=20’000)
No DES (15’000) BMS (5’000)
12 vs. 30 NYK NYK Ongoing
OPTIMIZE (n=3’120)
No E-ZES 3 vs. 12 NYK NYK Ongoing
ZEUS (n=1’600)
Yes ZES vs. BMS 1 (stable) 6+ (ACS)
NYK NYK Ongoing
ISAR-SAFE (n= 6’000)
No DES
6 vs. 12 NYK NYK Ongoing
ISAR TRIPLE (n= 600)
No DES 1.5 vs. 6 (all on AVK)
NYK NYK Ongoing
ETUDES RANDOMISEES SUR LA DUREE DE LA DOUBLE AAP après STENT ACTIF
Trial Also comparing stents
Devices DAPT duration (months)
Thrombotic events Bleeding events
Status
DES LATE (n=2’701) No SES, PES, ZES
12 vs. 24 No difference (card.death, MI)
No difference (TIMI maj.)
Published (NEJM 2010)
PRODIGY (n=2’013) No BMS(25%), ZES, PES, EES
6 vs. 24 No difference (death,MI,CVA)
6 mth better (BARC)
Published (Circulation 2012)
RESET (n=2’117) Yes E-ZES vs. SES, EES, ZES
3 (E-ZES) vs.12
(other DES)
No difference (death,MI,ST)
No difference Presented (ACC 2012)
EXCELLENT (n=1’443)
Yes EES & SES 6 vs. 12 No difference (TVF)
No difference (TIMI maj.)
Published (Circulation 2012)
DAPT (n=20’000)
No DES (15’000) BMS (5’000)
12 vs. 30 NYK NYK Ongoing
OPTIMIZE (n=3’120)
No E-ZES 3 vs. 12 NYK NYK Ongoing
ZEUS (n=1’600)
Yes ZES vs. BMS 1 (stable) 6+ (ACS)
NYK NYK Ongoing
ISAR-SAFE (n= 6’000)
No DES
6 vs. 12 NYK NYK Ongoing
ISAR TRIPLE (n= 600)
No DES 1.5 vs. 6 (all on AVK)
NYK NYK Ongoing
ETUDES RANDOMISEES SUR LA DUREE DE LA DOUBLE AAP après STENT ACTIF
XIENCE V USA: THROMBOSE DE STENT entre 30 j et 1AN
Après interruption de la double anti-agrégation
ETUDES CLINIQUES DU XIENCE pour le marquage CE
INERRUPTION DES ANTI-AGREGANTS à 3 MOIS
THROMBOSES DE STENT et INTERRUPTION DES AAP
ETUDES sur LE XIENCE
RECOMMENDATIONS EUROPEENNES 2010
Birth of a concept (May 2011)
A forgotten patient population
A new polymer-free metallic stent
Current DAPT trend :
« shorter is better »
Urban, oral presenation, EuroPCR 2012
Age ≥ 75 years
Oral anticoagulants needed after PCI
Planned major surgery (within next year)
Baseline Hb <11 g/dl or TF during prior 4 weeks
Hospital admission for bleeding during past year
Any prior intra-cerebral bleed
Any stroke during the past year
Cancer diagnosed or treated < 3 years
Main inclusion criteria
Urban, oral presenation, EuroPCR 2012
Age ≥ 75 years
Oral anticoagulants needed after PCI
Planned major surgery (within next year)
Baseline Hb <11 g/dl or TF during prior 4 weeks
Hospital admission for bleeding during past year
Any prior intra-cerebral bleed
Any stroke during the past year
Cancer diagnosed or treated < 3 years
Main inclusion criteria
Urban, oral presenation, EuroPCR 2012
Trial design
• Biosensors BioFreedom™ BA9 Drug-Coated Coronary Stent (DCS).
• Biosensors Gazelle™ Bare Metal Coronary Stent (BMS)
Two stents
• ASA 100-160 mg OD, indefinitely
• Clopidogrel 75 mg OD (or another P2Y12 inhibitor) for one month only
One DAPT regimen
Urban, oral presenation, EuroPCR 2012
Clinical Follow-Up
Primary safety endpoint: Composite of cardiac death, MI, definite/probable stent thrombosis at 1 year
(Non-inferiority)
Primary efficacy endpoint: Clinically driven TLR at 1 year
(Superiority)
DAPT mandated for 1 month only, followed by long term SAPT
BioFreedom™
DCS
Gazelle™
BMS
Prospective, multi-center, multi-national, double blinded randomized trial
High Bleeding Risk PCI population
(ACS + Elective stable patients)
LEADERS FREE Trial Design
1:1 randomization
1 mo 2 mo 4 mo 1 yr 2 yr
2500 patients in 60 centers worldwide
PI: Philip Urban
RECOMMENDATIONS
EUROPEENNES 2015
Durée de la double Antiagrégation
Plaquettaire après STENT ACTIF
3 mois pour les patients standards avec stents
actifs de seconde génération. I C
1 mois pour les patients à haut risque hémorragique
Avec le stent BIOFREEDOM I A