Optimal DAPT choices for high-bleeding risk patients

A challenging patient with oral anticoagulant therapyIs there an alternative strategy?

Christian Spaulding, MD, PhD, FACC, FESC

Hôpital Européen Georges Pompidou, Paris, France

Speaker's name: Christian Spaulding

I have the following potential conflicts of interest to report:

Receipt of honoraria or consultation fees:

• Abiomed, Zoll, Medtronic, Medpass, Astra-Zeneca, Cordis, Servier, Lead-Up, Bayer, the Medicines Company, Eli Lilly, WebMD.

Research grant from the French Ministry of Health

Potential conflicts of interest

The differences between French and Swiss

interventional cardiologists

Mr. JCA - 71 year old (born 1945)

Ad-hoc PCI or planned procedure ?Radial or femoral approach ?Which stent : DES or BMS?

Duration of DAPT?

Multidisciplinary approach

• The case clearly needs a consensus between the interventional cardiologist, the referring cardiologist, the surgeon and the anesthesiologist, and the patient !

Planned PCI procedure with pre-defined strategy after a consensus meeting

Meta-analysis of MACE in randomised studies comparing radial and femoral access for PCI

Hamon M et al, EuroIntervention 2013;8:1242-1251 MACE: major adverse cardiac eventsPCI: percutaneous coronary intervention

Radial approach if technically feasible by a trained operator

DES >>> BMS

Mehran R et al, Lancet 2013; 382: 1714–22

ESC 2014 ESC/EACTS Guidelines on myocardial revascularization

Windecker S et al, Eur Heart J. 2014;35:2541-619

Duration of DAPT ?

2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease

PCI: percutaneous coronary intervention, DAPT: dual antiplatelet therapy, DES: drug eluting stent, BMS: bare metal stent, mo: month, y: year

Levine GN et al, J Am Coll Cardiol, 2016

Joint consensus document on the management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or

undergoing percutaneous coronary or valve interventions

Lip YH et al, EHJ 2016

5.6

2.5

1.9

2.5

5.0

1.21.6

1.0 1.0

1.5

2.9

0.4

0

2

4

6

8

Any Death Cardiac Death TV related MI cd TLR TLF ST

%

OAC, N=160

Non-OAC, N=3411

P=0.002 P=0.09 P=0.22 P=0.31 P=0.18P=0.14

E-ULTIMASTER – Global registry

Clinical outcomes at 1 year

Patients on OAC

Different DAPT regiment

2.9 2.9

0.0

5.7 5.7

0.0

4.0 4.0

0.0

4.0 4.0

0.00.0 0.0

5.9 5.9 5.9

0.0

8.4

3.6

2.4

3.6

7.2

1.2

0

2

4

6

8

10

12

Death MI TLR TLF Bleeding ST

No DAPT at

Discharge +

Stopped <1m,

never resumed,

N°=35

No DAPT at

Discharge + Stopped

<1m, resumed DAPT

before 3m, N°=25

Stopped DAPT

between 1 and 3

months, N°=17

Continued DAPT

after 3 months,

N°=83

NS

%

An alternative strategy

• Planned PCI procedure after consensus meeting

• Radial approach

• DES

• Duration of DAPT and date of surgery:– According to the guidelines: 3 to 6 months

– One month ? : need for randomized data on DES and short duration of DAPT

• Randomize in MASTER DAPT !