jnuc 2014 f beygui final
TRANSCRIPT
Que retenir de l’ACC 2014, l’AHA 2014, l’ESC 2014 et le TCT 2014 ?
F Beygui
Bivalirudine supérieur à l’héparine dans le STEMI? Heat trial ACC 2014; Lancet 2014
Dr Adeel Shahzad Dr Rod Stables (PI)
Liverpool Heart and Chest Hospital Liverpool, UK
How Effective are Antithrombotic Therapies in PPCI
Assigned to Heparin 914
Included in analysis 907
915 Assigned to Bivalirudin
905 Included in analysis
Consent not available in surviving paMents
Consent not available in surviving paMents 7 10
Received allocated Rx 900 Received no study drug 14 Treatment cross-‐over 0 LMWH pre-‐procedure 3
907 Received allocated Rx 7 Received no study drug 1 Treatment cross-‐over 4 LMWH pre-‐procedure
CharacterisMc Bivalirudin (%) Heparin (%)
P2Y12 use -‐ Any 99.6 99.5
-‐ Clopidogrel 11.8 10.0
-‐ Prasugrel 27.3 27.6
-‐ Ticagrelor 61.2 62.7
GPI use 13.5 15.5
Radial arterial access 80.3 82.0
PCI performed 83.0 81.6
Bivalirudin Heparin n % % n
MACE 79 8.7 % v 5.7 % 52
Absolute risk increase = 3.0% (95% CI 0.6, 5.4)
RelaMve risk = 1.52 (95% CI 1.1 – 2.1) P=0.01
Bivalirudin Heparin n % % n
Death 46 5.1 % v 4.3 % 39
CVA 15 1.6% v 1.2% 11
ReinfarcMon 24 2.7% v 0.9% 8
TLR 24 2.7% v 0.7% 6
Any MACE 79 8.7 % v 5.7 % 52
Bivalirudin Heparin n % % n
All Events 24 3.4 % v 0.9 % 6
RelaMve risk = 3.91 (95% CI 1.6 -‐ 9.5) P=0.001
ARC definite or probable stent thrombosis events
Bivalirudin Heparin n % % n
Minor Bleed 83 9.2 % v 10.8 % 98
Major or Minor 113 12.5 % v 13.5 % 122
Minor Bleed P=0.25 Major or Minor P=0.54
Major Bleed BARC grade 3-‐5 Minor Bleed BARC grade 2
Ticagrelor en pré-‐hospitalier versus intra-‐hospitalier ATLANTIC trial ESC 2014; NEJM 2014
Study popula+on and design
Median +mes to pre-‐ and in-‐hospital steps
1st Co-‐primary endpoint No ST-‐segment resolu+on (≥70%)
2nd Co-‐primary endpoint No TIMI 3 flow in infarct-‐related artery
Major adverse CV events up to 30 days
Non-‐CABG-‐related bleeding events (PLATO defini+ons) -‐ Safety popula+on
Definite stent thrombosis up to 10 days
Absence of ST-‐segment resolu+on by pa+ent characteris+cs
Prasugrel TRANLATE ACS trial, TCT 2014
TReatment with ADP receptor iNhibitorS: Longitudinal Assessment of Treatment patterns
and Events after Acute Coronary Syndrome
TCT 2014 First Report Investigation presented on behalf of the TRANSLATE-ACS Investigators
ADP Receptor Inhibitor Selection
Clopidogrel n=8,846 (72.3%)
Prasugrel n=3,123 (25.5%)
Ticagrelor Ticlopidine
Current analysis will focus on 11,969 patients treated initially with clopidogrel or prasugrel
n=258 (2.1%)
Unadjusted MACE C
umul
ativ
e In
cide
nce
(%)
Clopidogrel Clopidogrel
Prasugrel Prasugrel
13.1% vs. 17.1% p<0.0001
13.5% vs. 17.3% p<0.0001
As Treated Intention to Treat
MACE = death, MI, stroke, or unplanned revascularization
Cum
ulat
ive
Inci
denc
e (%
)
Adj. HR 95% CI P
Primary Analysis IPW (as treated) 1.03 0.92 – 1.16 0.59
Secondary Analyses IPW (ITT) 1.00 0.91 – 1.11 0.95
Propensity-matched (as treated) 1.02 0.90 – 1.14 0.81 Propensity-matched (ITT) 1.03 0.93 – 1.14 0.57
Trimmed population (as treated) 0.89 0.76 – 1.05 0.18 Trimmed population (ITT) 0.91 0.79 – 1.06 0.23
Adjusted MACE
HR = hazard ratio; CI = confidence interval IPW = inverse probability weighting; ITT = intention-to-treat
Stent Thrombosis C
umul
ativ
e In
cide
nce
(%)
Clopidogrel Clopidogrel
Prasugrel Prasugrel
0.97% vs. 1.24%, p=0.11
Adj. HR 0.54 (0.33-0.89), p=0.02 0.98% vs. 1.33%, p=0.12
Adj. HR 0.63 (0.42-0.97), p=0.04
As Treated Intention to Treat
Stent thrombosis = ARC definite stent thrombosis
Cum
ulat
ive
Inci
denc
e (%
)
Adj. HR 95% CI P
Primary Analysis IPW (as treated) 1.30 1.04 – 1.63 0.02
Secondary Analyses IPW (ITT) 1.30 1.07 – 1.59 0.01
Propensity-matched (as treated) 1.12 0.86 – 1.47 0.41 Propensity-matched (ITT) 1.10 0.88 – 1.37 0.43
Trimmed population (as treated) 0.94 0.64 – 1.36 0.73 Trimmed population (ITT) 0.83 0.58 – 1.18 0.29
Adjusted Bleeding
HR = hazard ratio; CI = confidence interval IPW = inverse probability weighting; ITT = intention-to-treat
Multi-‐vessel Disease in the setting of ACS
Ø 30-‐40% in the seTng of STEMI Muller DW, et al Multivessel coronary artery disease: a key predictor of short-‐term prognosis after reperfusion therapy for acute myocardial infarction. Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study Group. Am Heart J 1991;121:1042-‐9 Toma M,, et al. Non-‐culprit coronary artery percutaneous coronary intervention during acute ST-‐segment elevation myocardial infarction: insights from the APEX-‐AMI trial. European Heart Journal 2010;31:1701-‐7
Ø 44-‐60% in the seTng of NSTEMI Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-‐Q-‐wave myocardial infarction. Results of the TIMI IIIB Trial. Thrombolysis in Myocardial Ischemia. Circulation 1994;89:1545–1556. Invasive compared with non-‐invasive treatment in unstable coronary-‐artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators. Lancet 1999;354:708–715.
ATL: revasculariser l’artère responsable ou toutes les artères dans le STEMI CvLPRIT trial ESC 2014
Footer Text 28
Variable IRA only (N=146)
Complete Revascularisation
(N=150)
P value
ASA plus
Clopidogrel (%)
Ticagrelor (%)
Prasugrel (%)
Warfarin (%)
131/135 (97.0)
54/138 (39.1)
18/135 (13.3)
64/138 (46.4)
2/138 (1.5)
141/142 (99.3)
59/144 (41.0)
19/144 (13.2)
58/144 (40.3)
1/147 (0.7)
0.16
0.75
0.97
0.30
0.61
GPI (%)
44/139 (31.7) 46/145 (31.7) 0.99
Bivalirudin (%)
65/128 (50.8) 79/139 (56.8) 0.32
TIMI 0/1 on arrival (%)
118/140 (84.3) 120/147 (81.6) 0.55
Thrombus aspiration cath % 105/140 (75.0) 93/145 (64.1) 0.047
DES (%)
127/140 (90.7) 141/147 (95.9) 0.08
No. DES stents/patient 1 ( 1, 2) 3 (2, 4) < 0.0001
Total Procedure time (mins) 41 (30, 55.5) 55 (38, 74) < 0.0001
Total contrast used (mls) 190 (150, 250) 250 (190, 330) < 0.0001
29
Results 1: Percent MACE at 12 months
The primary endpoint composite of total mortality, recurrent MI, heart failure and ischaemia-‐driven revascularisaMon at 12 months
IRA Only Complete Revascularisation
Variable IRA only
(N=146)
Complete Revascularisation
(N=150)
HR (95% CI) P value
Time to First Event MACE N= (%) 31 (21.2) 15 (10.0) 0.45 (0.24, 0.84) 0.009
Components N=(%)
All-‐cause mortality 6 (4.1) 2 (1.3) 0.32 (0.06, 1.60) 0.14
Recurrent MI 4 (2.7) 2 (1.3) 0.48 (0.09, 2.62) 0.39
Heart failure 9 (6.2) 4 (2.7) 0.43 (0.13, 1.39) 0.14
Repeat Revascularisation
12 (8.2) 7 (4.7) 0.55 (0.22, 1.39) 0.2
Total number of events reported N= (%) All-‐cause mortality 10 (6.9) 4 (2.7) 0.38 (0.12, 1.20) 0.09 Recurrent MI 4 (2.7) 2 (1.3) 0.47 (0.09, 2.59) 0.38 Heart Failure 10 (6.9) 5 (3.3) 0.47 (0.16, 1.38) 0.16 Repeat Revascularisation
16 (11.0) 8 (5.3) 0.46 (0.20, 1.08) 0.07
Safety N= (%) CV mortality 7 (4.8) 2 (1.3) 0.27 (0.06, 1.32) 0.11 Stroke 2 (1.4) 2 (1.3) 0.95 (0.13, 6.77) 0.96 Major Bleed 7 (4.8) 4 (2.7) 0.55 (0.16, 1.87) 0.34 CIN 2(1.4) 2 (1.4) 0.94 (013,6.75) 0.95
05/12/14 Footer Text 31
Overall (I-squared = 0.0%, p = 0.756)
DiMario 2004
Politi 2010
Gershlick 2014
Wald 2013
Study
ID
0.34 (0.24, 0.47)
0.49 (0.15, 1.63)
0.27 (0.15, 0.50)
0.41 (0.21, 0.80)
0.33 (0.19, 0.57)
OR (95% CI)
100.00
5.75
32.29
22.80
39.16
%
Weight
1.1 1 10Favours Multi-vessel PCI Favours Culprit-only PCI
MACE
Overall (I-squared = 0.0%, p = 0.745)
Study
Politi 2010
Gershlick 2014
Wald 2013
DiMario 2004
ID
0.55 (0.33, 0.91)
0.46 (0.19, 1.09)
0.37 (0.11, 1.22)
0.73 (0.34, 1.57)
1.02 (0.04, 26.19)
OR (95% CI)
100.00
%
36.05
24.39
37.77
1.79
Weight
1.1 1 10
Favours Multi-vessel PCI Favours Culprit-only PCI
Mortality
ATL: revasculariser l’artère responsable ou toutes les artères dans le NSTEMI? SMILE trial TCT 2014
SMILE TRIAL
Therapy SINGLE Staged (tot. = 253) MULTI Staged (tot. = 247) p value Thienopyridines pre-‐randomiza+on Clopidogrel 75 mg Clopidogrel 300 mg Clopidogrel 600 mg Prasugrel 60 mg Prasugrel 5 mg Ticagrelor 90 mg Ticagrelor 180 mg
42 (16.66) 49 (19.36) 53 (20.94) 2 (0.79) 0 106(41.89) 1 (0.39)
21 (8.50) 55 (22.26) 60 (24.29) 4 (1.62) 2 (0.81) 102 (41.29) 3 (1.21)
0.64
Gp IIb/IIIa Inhibitors – no. (%) None Abciximab Tirofiban Ep+fiba+de
219 (86.56) 10 (3.95) 12 (4.74) 12 (4.74)
214 (86.64) 9 (3.64) 13 (5.26) 11 (4.45)
0.47
Thienopyridines post-‐procedure Clopidogrel 75 mg Prasugrel 10 mg Prasugrel 5 mg Ticagrelor 90 mg
109 (43.08) 2 (0.79) 0 140 (55.33)
105 (42.51) 4 (1.62) 2 (0.81) 136 (55.06)
0.71
An+-‐aggrega+on therapy at Hospitaliza+on
SMILE TRIAL
Characteris+cs SINGLE Staged (tot. =253) MULTI Staged (tot. =247) P value
MACCE – no. (%) Death – no. (%) Cardiac Death – no. (%) Stroke – no.(%) Myocardial Infarc+on Q – no. (%) non-‐Q – no. (%) UA needing Hospitaliza+on TVR – no. (%)
33 (13.04) 14 (5.53) 9 (3.55) 1 (0.39) 7 (2.76) 2 (0.78) 5 (1.98) 11 (4.34) 22 (8.69)
57 (23.07) 28 (11.33%) 13 (5.26%) 0 9 (3.64) 3 (1.21) 6 (2.42) 13 (5.26) 36 (14.57%)
0.0036 0.02 0.38 1 0.61 0.68 0.76 0.67 0.05
Definite Stent thrombosis 1 (0.39) 1 (0.40) 1.00 Bleedings – no. (%)
4 (1.56)
12(4.85)
0.03
12 months Clinical Events
SMILE TRIAL
Bithérapie anMagrégante: quelle durée
• SECURITY trial: 6 vs 12 Mo; TCT 2014 • TLPAS trial: prasugrel 12 vs 30 Mo; AHA 2014 • ITALIC trial: 6 vs 24 Mo; AHA 2014 • ISAR safe trial: 6 vs 12 Mo; AHA 2014 • DAPT trial: 12 vs 30 Mo; AHA 2014
Second Genera+on Drug-‐Elu+ng Stents Implanta+on Followed by Six Versus Twelve-‐Month -‐ Dual Antiplatelet
Therapy -‐ The SECURITY Randomized Clinical Trial
Antonio Colombo MD on behalf of
the SECURITY Inves@gators
Baseline Clinical Characteris+cs Characteris+cs 6-‐Month DAPT (N = 682) 12-‐Month DAPT (N = 717)
Age (years), mean ± SD 64.9 ± 10.2 65.5 ± 10.1
Female sex, n (%) 153 (22.4) 166 (23.2)
Diabetes Mellitus, n (%) 206 (30.4%) 223 (31.4%)
Hypertension, n (%) 508 (74.5) 510 (71.1)
Dyslipidemia, n (%) 446 (65.4) 436 (60.8)
Smoker Status, n (%)
Never Smoked 274 (40.5) 261 (37)
Previous Smoker 239 (35.3) 238 (33.7)
Ac+ve Smoker 139 (20.5) 172 (24.4)
Previous MI, n (%)
NSTEMI > 48 h 65 (9.5) 71 (9.9)
STEMI > 48 h 80 (11.7) 73 (10.2)
Previous PCI, n (%) 132 (19.4) 116 (16.2)
Previous CABG, n (%) 38 (5.6) 39 (5.4)
LVEF (%), mean ± SD 56.3 ± 8.7 56.6 ± 8.2
Clinical Presenta+on, n (%)
Stable Angina 341 (61.6) 368 (61.6)
Unstable Angina 213 (38.4) 229 (38.4)
Baseline Medica+ons
Aspirin, n (%) 616 (90.3) 621 (86.6)
Clopidogrel, n (%) 301 (44.1) 305 (42.5)
Sta+n, n (%) 489 (71.7) 494 (68.9)
Heparin, n (%) 377 (55.3) 401 (55.9)
Primary and Secondary Composite Endpoints
P = NS
P = NS
P = NS
Stent Thrombosis
P = NS P = NS P = NS P = NS
Definite / Probable Stent Thrombosis Possible Stent Thrombosis
Increased Risk of Ischemic Events Upon Discontinuation of Prasugrel After 12 or 30 Months of Therapy
Following Placement of the TAXUS Liberté Paclitaxel- Eluting Coronary Stent
Kirk N. Garram, Ronald D. Jenkins, Thomas K. Pow, W. Douglas Weaver, Laura M. Mauri, Dean J. Kereiakes, Kenneth J. Winters, Thomas Christen, Dominic J.
Allocco, and David P. Lee
Baseline Characteristics Characteristic (%, unless noted)
12-month Prasugrel + ASA N=1093 patients
30-month Prasugrel + ASA N=1098 patients
Characteristic (%, unless noted)
12-month Prasugrel + ASA N=1093 patients
30-month Prasugrel + ASA N=1098 patients
Male 74.6 76.3 PCI History 30.9 28.1
Age (years) 59.2 ± 9.5 59.6 ± 9.7 CABG History 12.8 12.0
Age >75 years 2.7 3.8 Bleeding disorder 0.3 0.5
Weight <60 kg 3.5 3.2 Stable angina 30.6 29.4
Diabetes* 27.3 31.4 Unstable angina 32.6 34.5
Metabolic Syndrome 12.5 15.7 Silent ischemia 8.0 8.3
Hyperlipidemia* 69.7 68.1 MI 28.2 27.3
Hypertension* 71.0 71.9 NSTEMI 17.9 15.5
MI History 20.3 20.3 STEMI 9.5 10.7
Numbers are % or mean ± SD; *Medically-treated; MI=myocardial infarction; PCI=percutaneous coronary intervention; CABG=coronary artery bypass graft
At Risk 0 90 180 360 540 630 1093 1089 1055 1030 987 935
1097 1094 1080 1065 1034 991
Co-Primary Endpoint: MACCE at 540 days All Death, ARC MI, Stroke
Time after Randomization (days)
14
12
10
8
6
4
2
0
Cum
ulat
ive
Inci
denc
e of
M
AC
CE,
% (±
1.5
SE)
9.4%
5.8%
540 Days P<0.001
630 Days P<0.001
90 Days P=0.002
8.8%
3.7%
Cumulative KM Event Rate ± 1.5 SE; log-rank P value; HR=Hazard Ratio [95% confidence interval]
2.4%
0.7%
HR 0.303 [0.137, 0.670]
HR 0.407 [0.281, 0.589]
HR 0.591 [0.431, 0.811]
12-mo Prasugrel + ASA 30-mo Prasugrel + ASA
Co-Primary Endpoint: Definite or Probable ARC Stent Thrombosis at 540 days
At Risk 0 90 180 360 540 630 1093 1087 1065 1042 1011 969
1097 1091 1081 1068 1043 1004
14
12
10
8
6
4
2
0
Cum
ulat
ive
Inci
denc
e of
A
RC
ST,
% (±
1.5
SE)
Cumulative KM Event Rate ± 1.5 SE; log-rank P value; HR=Hazard Ratio [95% confidence interval]
2.9%
0.8%
540 Days P<0.001
630 Days P<0.001
90 Days P=0.003
0.8% 0.0%
2.9%
0.2%
Time after Randomization (days) HR 0.000 [0.000, NA]
HR 0.063 [0.015, 0.264]
HR 0.252 [0.116, 0.549]
12-mo Prasugrel + ASA 30-mo Prasugrel + ASA
Chicago 2014
Six-‐month versus 24-‐month dual an+platelet therapy ajer implanta+on of drug elu+ng stents
in pa+ents non-‐resistant to aspirin: ITALIC, a randomized mul+center trial
Is There A LIfe for DES ajer discon+nua+on of Clopidogrel
Gilard M, Barragan P, AL Noryani A, Noor H AMajwal T, Hovasse T, Castellant P, Schneeberger M, Maillard L, Bressoleme E, Wojcik J, Delarche N, Blanchard D, Jouve B, Ormezzano O, Paganelli F, Levy G, Sainsous J, Carrie D, Furber Berlan J, Darremont O, Le Breton H, Lyuycx-‐Bore A, Gommeaux A, Cassat C, Kermarrec A, Cazaux P, Druelles P, Dauphin R, Armengaud J, Dupouy P, Champagnac D, Ohlmann P, Endresen K, Ben Amer H, Kiss R G,; Ungi I, Boschat J, Morice MC
Results Baseline Characteris+cs
Results 1-‐year clinical outcomes in the inten+on-‐to-‐treat study popula+on
Six versus Twelve Months of Clopidogrel Therapy
After Drug-Eluting Stenting
Stefanie Schulz-Schüpke, Julinda Mehilli, Karl-Ludwig Laugwitz, Franz-Josef Neumann, Jurrien M ten Berg, Tom Adriaenssens, Yaling Han, Barbara von Merzljak, Gert Richardt, Melchior Seyfarth, Klaus Tiroch, Tanja Morath, Michael Maeng, Bernhard Zrenner, Nonglag Rifatov, Claudius Jacobshagen, Harald Mudra, Eberhard von Hodenberg, Jochen Wöhrle, Sebastian Kufner, Christian Hengstenberg, Marcus Fischer, Martin Schmidt, Franz Dotzer, Tareq Ibrahim, Peter Sick, Christoph A Nienaber, Arnoud W J van 't Hof, Takeshi Kimura, Bernhard Witzenbichler, Stephan Windecker, Heribert Schunkert, Adnan Kastrati
– the Randomized, Double-Blind, Placebo-Controlled ISAR-SAFE Trial
Angiographic and Procedural Characteristics (1/2)
Six months Clopidogrel (n=1997)
Twelve months Clopidogrel (n=2003)
Clinical Presentation, % - Stable CAD 48.6 47.8 - NSTE-ACS 31.9 32.0 - STEMI 7.9 8.3 - Silent Ischemia 10.9 11.3 - Arrhythmia 0.7 0.6
0
1
2
3
4
5
0 1 2 3 4 5 6 7 8 9
12 months of clopidogrel
6 months of clopidogrel
Months ater randomizaMon
Compo
site of d
eath, M
I, sten
t throm
bosis,
stroke or T
IMI m
ajor bleed
ing (%
)
Primary Endpoint
1.6%
1.5%
Δ -0.1%, 1-sided 95% CI 0.5%, P Noninferiority <0.001
Placebo better 22
Continued thienopyridine better
Factor N HR and 95% CI Interaction P
0.22 < 75 Years N=8929 0.69 (0.57,0.83) >= 75 Years N=1032 0.95 (0.59,1.52)
0.46 Male N=7435 0.69 (0.56,0.85)
Female N=2526 0.81 (0.56,1.17)
0.01 No diabetes N=6924 0.59 (0.46,0.74) Diabetes N=3037 0.95 (0.72,1.25)
0.41 No Risk Factors for ST N=5162 0.78 (0.60,1.03)
Risk Factors for ST N=4799 0.67 (0.53,0.86)
0.03 Clopidogrel N=6500 0.80 (0.64,1.01) Prasugrel N=3461 0.52 (0.38,0.71)
0.048 Sirolimus N=1118 0.54 (0.31,0.93) Zotarolimus N=1264 0.76 (0.44,1.30) Paclitaxel N=2666 0.52 (0.37,0.71) Everolimus N=4703 0.89 (0.67,1.18)
Consistency of Treatment Effect MACCE (12-30 Months)
Oxygen in STEMI? Avoid trial; AHA 2015
Characteristic Oxygen Arm N=218
No Oxygen Arm N=223
Status on arrival at the catheterization laboratory Pain score, median (IQR) 2.0 (0.0-‐4.0) 2.0 (0.5-‐3.5) Time from Paramedic on scene to hospital arrival, median (IQR) 55.0 (46.0, 69.0) 56.5 (48.0, 68.8)
Cardiac arrest, % 4.6 3.6 Cardiogenic Shock, % 5.0 5.4
95%
96%
97%
98%
99%
100%
Arrival of
paramedics
Arrival at
hospital
Arrival at
cath lab
2 hours post
procedure
4 hours post
procedure
Oxygen Arm
No Oxygen Arm
SpO2 in patients with STEMI
P trend <0.01
% of patients receiving oxygen
P trend <0.01
Primary Endpoint Infarct Size
Area under curve p = 0.04
Creatine kinase, U/L Oxygen Arm N=217
No Oxygen Arm N=222
Ratio of means (Oxygen/No Oxygen) P-‐value
Geometric Mean Peak (95% CI) 1948 (1721 – 2205) 1543 (1341 – 1776) 1.26 (1.05 – 1.52) 0.01
Median Peak (IQR) 2073 (1065, 3753) 1727 (737, 3598) 0.04
Clinical Endpoints Values are %
Oxygen Arm N=218
No Oxygen Arm N=223
P-‐Value
At Hospital Discharge Mortality 1.8 4.5 0.11
Recurrent myocardial infarction 5.5 0.9 <0.01
Stroke 1.4 0.4 0.30
Major bleeding 4.1 2.7 0.41
SigniWicant arrhythmia 40.4 31.4 0.05
ECG ST-‐segment resolution > 70% 62.0 69.6 0.10
At 6 months follow up
Mortality 3.8 5.9 0.32
Recurrent myocardial infarction 7.6 3.6 0.07
Stroke 2.4 1.4 0.43
Repeat revascularization 11.0 7.2 0.17
MACCE 21.9 15.4 0.08
ESC 2014 guidelines on revascularisa6on PCI in STEMI
ESC 2014 guidelines on revascularisa6on PCI in NST ACS
An6thrombo6c therapy in NST ACS ACC/AHA guidelines 2014
ESC 2014 guidelines on revascularisaMon PCI in NST ACS
In summary, it is recommended that DAPT be administered for at least 1 month ater BMS implantaMon in SCAD, for 6 months ater new-‐genera+on DES implantaMon in SCAD, and for up to 1 year in paMents ater ACS, irrespecMve of
revascularizaMon strategy
67
Aspirine: faut-‐il meIre les pa6ents sous aspirine avant chirurgie non cardiaque? POISE-‐2 trial ACC 2014, NEJM 2014
Type of surgery and periop an+coagulant prophylaxis Surgery Aspirin
(N=4998) Placebo (N=5012)
Orthopedic General Urologic or gynecologic Vascular Other
38.2 26.8 16.7 6.2 12.1
39.2 26.8 16.8 5.9 11.3
65% of paMents received prophylacMc anMcoagulant
1O and 2O outcome results
Outcome Aspirin (4998)
Placebo (5012)
HR (95% CI)
P
1O outcome: death or nonfatal MI
351 (7.0)
355 (7.1)
0.99 (0.86-‐1.15)
0.92
2O outcomes: death, MI, or stroke
362 (7.2)
370 (7.4)
0.98 (0.85-‐1.13)
0.80
death, MI, revasc, PE, DVT 402 (8.0) 407 (8.1) 0.99 (0.86-‐1.14) 0.90
No interacMon with clonidine study drug
Safety outcome results
Outcome Aspirin (4998)
Placebo (5012)
HR (95% CI)
P
Major bleed 229 (4.6) 187 (3.7) 1.23 (1.01-‐1.49) 0.04
Life-‐threat bleed
87 (1.7)
73 (1.5)
1.19 (0.88-‐1.63) 0.26
Stroke 16 (0.3) 19 (0.4) 0.84 (0.43-‐1.64) 0.62
LCZ696, angiotensin receptor neprilysin inhibitor PARADIGM HF trial, ESC 2014; NEJM 2014
05/12/14 Footer Text 73
LCZ696
LCZ696: Angiotensin Receptor Neprilysin Inhibition
Angiotensin receptor blocker
Inhibition of neprilysin
0
16
32
40
24
8
Enalapril (n=4212)
360 720 1080 0 180 540 900 1260 Days After Randomization
4187 4212
3922 3883
3663 3579
3018 2922
2257 2123
1544 1488
896 853
249 236
LCZ696 Enalapril
Patients at Risk
1117
Kap
lan-
Mei
er E
stim
ate
of
Cum
ulat
ive
Rat
es (%
)
914
LCZ696 (n=4187)
HR = 0.80 (0.73-0.87) P = 0.0000002
Number needed to treat = 21
PARADIGM-HF: Cardiovascular Death or Heart Failure Hospitalization (Primary Endpoint)
Enalapril (n=4212)
LCZ696 (n=4187)
HR = 0.80 (0.71-0.89) P = 0.00004
Number need to treat = 32
Kap
lan-
Mei
er E
stim
ate
of
Cum
ulat
ive
Rat
es (%
)
Days After Randomization
4187 4212
4056 4051
3891 3860
3282 3231
2478 2410
1716 1726
1005 994
280 279
LCZ696 Enalapril
Patients at Risk
360 720 1080 0 180 540 900 1260 0
16
32
24
8
693
558
PARADIGM-HF: Cardiovascular Death