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Doppia antiaggregazione dopo impianto di DES: prolungata... ma non troppo? Doppia antiaggregazione dopo impianto di DES: prolungata... ma non troppo? UO.

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Presentation on theme: "Doppia antiaggregazione dopo impianto di DES: prolungata... ma non troppo? Doppia antiaggregazione dopo impianto di DES: prolungata... ma non troppo? UO."— Presentation transcript:

1 Doppia antiaggregazione dopo impianto di DES: prolungata... ma non troppo? Doppia antiaggregazione dopo impianto di DES: prolungata... ma non troppo? UO Cardiologia ASL 9 Grosseto UO Cardiologia ASL 9 Grosseto Ugo Limbruno Conflict of Interest: c Conflict of Interest: c onsulting for ABBOTT, CORDIS, BOSTON SCIENTIFIC, TERUMO, BIOTRONIK, PFIZER, ANGELINI, ASTRA ZENECA, TMC, IROKO.

2 risk ST without DAPT bleeds with DAPT time after DES 1 mo3 mo6 mo1 year DAPT duration NEJM 2010;362:1374 Heart 2009;95:1579 DAPT duration current practice ? ? DAPT duration

3 528 pts

4 Intentional DAPT withdrawalIntentional Unplanned Unplanned

5 0.3%/year Intentional DAPT withdrawal Unplanned freedom from ST (%) 3-6%/year Mauri et al. N Engl J Med 2007;356:1020 Roy et al. Am J Cardiol 2009;103:801 Kimura et al. Circulation 2009;119:987

6 Bleeding Surgery Peptic ulcer Bleeding Surgery Peptic ulcer 70% ! Latib et al, Am J Cardiol 2008;102:1477–1481 Reasons for premature DAPT discontinuation

7 Bleeding Surgery Peptic ulcer Bleeding Surgery Peptic ulcer 70% ! Latib et al, Am J Cardiol 2008;102:1477–1481 Reasons for premature DAPT discontinuation Rossini et al, Am J Cardiol 2011;107:186–194

8 Kimura et al. Circulation 2009;119:987 J-Cypher Registry ( pts) Only Thieno withdrawal Only Thieno withdrawal ASA + Thieno withdrawal

9 Eisenberg, et al. Circulation 2009;119: pts with definite ST ASA+Thieno (simultaneous) ASA+Thieno (sequential) Thieno only 10 days >3 month

10 unplanned DAPT withdrawal Stent thrombosis Bleed, Surgery, Ulcer ASA + Thieno withdrawal Transfusion, Cancer: thrombophilic state prolonged DAPT

11 Kimura et al. Circulation 2009;119:987 J-Cypher Registry ( pts) 6-month landmark analysis

12 Kimura et al. Circulation 2009;119:987 vs ACS vs Non-ACS

13 Roy et al. Am J Cardiol 2009;103:801 WHC Registry (2.889 pts)

14 Clopidogrel treatment duration (days) Risk of ST at 4 years Schulz et al. Eur Heart J 2009;30: pts

15 Airoldi et al. Circulation 2007;116: %/year 2%/year Stent thrombosis (3021 pts) Bleeding Latib et al. Am J Cardiol 2008;102:1477

16 Bleeding & Outcome

17 ACC 2011 EXCELLENT trial (1428 pts)

18

19 2013 pts

20

21 ...tailored DAPT duration? 2010 guidelines 2010 guidelines

22 DES type & stent thrombosis DES type & stent thrombosis

23 9-month strut coverage after PPCI (46 pts) Fan et al. Am J Cardiol 2010;105:972

24 ZES % uncovered struts p=NS BMS OCTAMI trial (44 pts) OCT uncovered struts 6 month after PPCI Guagliumi, Musumeci et al. JACC Cardiovasc Interv 2010;3:680

25 BMS old old -DES new new -DES stent thrombosis SCAAR registry: stent thrombosis

26 DES for ISR (3-month OCT)

27 DESERT trial OCT: 6-month strut coverage Population Protocol End point DES 15 pts with de novo de novo lesion 15 pts with ISR after BMS

28 risk ST without DAPT bleeds with DAPT time 1 mo3 mo6 mo1 year DAPT duration current practice DAPT duration Accelerated reendothelization with 2 nd generation DES?

29 Major bleeding (%) Sibbing D et al, J Thromb Haemost 2010 over-responders major bleedings Response variability to clopidogrel

30 risk ST without DAPT bleeds with DAPT time 1 mo3 mo6 mo1 year DAPT duration current practice DAPT duration Over-respondersOver-responders Haemorrhagic diatesisHaemorrhagic diatesis Prasugrel, Ticagrelor?Prasugrel, Ticagrelor?

31 Parodi et al, JAMA 2011; 306: high low residual platelet reactivity 1789 pts p<0.002 Mortality & platelet reactivity after ACS cardiac mortality, %

32 ST without DAPT bleeds with DAPT Multiple stenting Left main stenting risk time 1 mo3 mo6 mo1 year DAPT duration current practice DAPT duration Thrombophillic state, low-responders Uncovered/malapposed struts at OCT?

33 Parodi et al, JAMA 2011; in press. high low residual platelet reactivity 1789 pts p<0.002 Mortality & platelet reactivity after ACS cardiac mortality, % thienopyridine dose-adjustment thienopyridine dose-adjustment low high residual platelet reactivity P= NS

34 ConclusioniConclusioni Aderenza alla DAPT cruciale nei primi 30gg!

35 Dopo 6 mesi la sospensione isolata di clopidogrel non è correlata, né quantitativamente né temporalmente, alla ST. La durata ottimale della DAPT potrebbe variare in funzione del tipo di DES, fattori clinici, complessità anatomica della PCI. Sospensione DAPT dopo 30 gg : - pianificata non pianificata - solo thieno ASA + thieno ConclusioniConclusioni

36 ConclusioniConclusioni...e la durata ottimale DAPT con Ticagrelor o Prasugrel?


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