PRACTICAL RECOMMENDATIONS ON ANTI- THROMBOTIC TREATMENT IN PATIENTS TREATED WITH DRUG-ELUTING STENTS Giuseppe Biondi-Zoccai Ospedale S. Giovanni Battista.

Slides:

Advertisements

Similar presentations

STENT THROMBOSIS: WHICH IMPACT IN REAL CLINICAL PRACTICE? Giuseppe Biondi Zoccai Divisione di Cardiologia, Università di Torino Ospedale S. Giovanni Battista.

Advertisements

Cardiology Morning Report: Revascularization in Stable Ischemic Heart Disease Bobby Mathew, MD LSU Internal Medicine, HO-II.

Gregg W. Stone MD for the ACUITY Investigators Gregg W. Stone MD for the ACUITY Investigators A Prospective, Randomized Trial of Bivalirudin in Acute Coronary.

Can we prevent stent restenosis after coronary stent implantation

Asymptomatic Carotid Surgery Trial ACST-2 Collaborators Meeting 2014 Pembroke College, Oxford Is recent coronary stenting a problem (or an opportunity)

Basel Stent Cost-effectiveness Trial-Late Thrombotic Events (BASKET LATE) Trial Basel Stent Cost-effectiveness Trial-Late Thrombotic Events (BASKET LATE)

Drug-Eluting Stent Mortality Meta-Analysis Presented at European Society of Cardiology Scientific Congress, September 2006 Presented by Dr. Alain J. Nordmann.

Call for CASES Leszek D. Stachaczyk, MD Pawel Buszman, MD, FESC, FSCAI American Heart of Poland, Ustroñ, Poland & CCU, Upper-Silesian Center of Cardiology,

Ten Points to Remember from the 2007 STEMI Guideline Update Based on the 2007 Focused Update of the 2004 Guidelines for the Management of Patients With.

SCAAR UCR SWEDEN 2007 Stefan James, Jörg Carlsson, Johan Lindbäck, Tage Nilsson, Ulf Stenestrand, Lars Wallentin and Bo Lagerqvist for the SCAAR study.

ACUTE CORONARY SYNDROMES:

Coronary Stenting: Drug-eluting vs Bare-metal Natalie Cleaver, PA-S Lock Haven University PA Program Evidence Based Medicine February 26, 2009.

RITA-3 Is this a benign lesion in a benign condition? Who Needs Angioplasty in 2008? Stable Angina Stable Angina Keith A A Fox Professor of Cardiology.

Applications of bivalirudin in interventional cardiology

1 SIROLIMUS-ELUTING STENTS FOR IN-STENT RESTENOSIS TREATMENT IN 278 UNSELECTED PATIENTS: INSIGHTS ON LONG-TERM OUTCOMES FROM A LARGE TWO-CENTER REGISTRY.

ARMYDA-4 (Antiplatelet therapy for Reduction of MYocardial Damage during Angioplasty) study Prospective, multicenter, randomized, double blind trial investigating.

Richard Melsheimer Director, Medical Affairs Europe Centocor Eli Lilly and Company Coordinated Use of ReoPro and Drug Eluting Stents: Rationale and Evidence.

Treatment of In-Stent Restenosis by Paclitaxel Coated PTCA Balloons Presented at The American Heart Association Scientific Session 2006 Presented by Dr.

PRODIGY Objective Study Design Primary Composite Endpoint

MANAGING ATHERO- THROMBOTIC RISK Early impact and long-term benefit of antiplatelet therapy What is the optimal duration of antiplatelet therapy? Giuseppe.

Antiplatelet therapy and PCI in unstable angina and NSTEMI Giuseppe Biondi Zoccai Divisione di Cardiologia, Università di Torino

COMPLETE REVASCULARIZATION IN ELDERLY - When it’s contraindicated

Giuseppe Biondi Zoccai University of Turin, Turin, Italy METCARDIO, Turin, Italy JOINT SYMPOSIUM WITH JACCT - Bologna, 25/9/2008.

¨ 8 European countries, 48 centres Stent implantation Double-blind randomisation n = 1005 Clopidogrel 300mg od Aspirin 325mg od Clopidogrel 75mg od Aspirin.

Effect of Intravascular Ultrasound- Guided vs. Angiography-Guided Everolimus-Eluting Stent Implantation: the IVUS-XPL Randomized Clinical Trial Myeong-Ki.

The Primary and Secondary Prevention of Cardiovascular Disease Per Olav Vandvik, MD, PhD A. Michael Lincoff, MD Joel M. Gore, MD David Gutterman, MD, FCCP.

Drug-eluting stent meta-analyses & Long-term follow-up of high-risk subsets: Reconciling the evidence DES e BMS: riflessioni e pensieri 23 febbraio 2007,

Giuseppe Biondi Zoccai University of Turin, Turin, Italy METCARDIO, Turin, Italy BMS & Sanofi Aventis Sponsored.

Is there any role for intravascular ultrasound in bifurcation lesions? Giuseppe Biondi-Zoccai, MD University of Turin, Turin, Italy.

Drug-Eluting Stents in Challenging Lesions: Randomized Trials and Registries.

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

Date of download: 6/25/2016 Copyright © The American College of Cardiology. All rights reserved. From: Medical Therapy With Versus Without Revascularization.

Date of download: 7/8/2016 Copyright © The American College of Cardiology. All rights reserved. From: Comprehensive Meta-Analysis of Safety and Efficacy.

Trial to Assess the Use of the Cypher Stent in Acute Myocardial Infarction Treated with Balloon Angioplasty (TYPHOON) Trial Presented at The American College.

Date of download: 7/8/2016 Copyright © The American College of Cardiology. All rights reserved. From: Benefit of Early Invasive Therapy in Acute Coronary.

1 R1 임준욱 Anticoagulant and Antiplatelet Therapy Use in 426 Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention and Stent Implantation.

Date of download: 9/18/2016 Copyright © The American College of Cardiology. All rights reserved. From: Incidence and Correlates of Drug-Eluting Stent Thrombosis.

From: Bivalirudin Versus Heparin With or Without Glycoprotein IIb/IIIa Inhibitors in Patients With STEMI Undergoing Primary Percutaneous Coronary Intervention:

The Primary and Secondary Prevention of Cardiovascular Disease

Prof. Dr. med. Sigmund Silber Cardiology Practice and Hospital

Disclosures Speaker’s bureau: Research support: Consulting: Equity

Figure 1 Ischaemic endpoints

Algorithm for preoperative management of patients taking antiplatelet therapy. ACS, acute coronary syndrome; BMS, bare metal stent; DES, drug-eluting stent;

Robert A. Guyton, MD The Annals of Thoracic Surgery

Figure 3 One-year adverse events (death, post-discharge myocardial infarction, revascularization) after PCI according to patients who (A) would not have.

Stenting of Coronary Arteries in Non Stress/Benestent Disease

Catheter-Based Treatment of Coronary Artery Disease

Glenn N. Levine et al. JACC 2016;68:

Glenn N. Levine et al. JACC 2016;68:

Giuseppe Biondi Zoccai

Robert A. Guyton, MD The Annals of Thoracic Surgery

Figure 3 Ischaemic outcomes in the ST-segment elevation myocardial

Diabetes mellitus in patients undergoing percutaneous drug-eluting stent implantation: short and long-term results Claudio Moretti, M.D. Division of Cardiology,

Giuseppe Biondi Zoccai University of Turin, Turin, Italy

Section F: Clinical guidelines

Giuseppe Biondi Zoccai, MD

2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease Glenn N. Levine, MD, FACC, FAHA,

Peter K. Smith, MD The Journal of Thoracic and Cardiovascular Surgery

Peter K. Smith, MD The Annals of Thoracic Surgery

NIPPON Trial design: Patients undergoing percutaneous coronary intervention were randomized to short-term dual antiplatelet therapy (DAPT) (6 months; n.

The American College of Cardiology Presented by Dr. Raimund Erbel

SURGERY EARLY AFTER DES IMPLANTATION

Incidence and management of restenosis after treatment of unprotected left main disease with drug-eluting stents: 70 restenotic cases from a cohort of.

Presented at TCT 2006.

Markov model scheme. Markov model scheme. Patients start (state 0) with uncomplicated PCI revascularisation; then cycle between health states until death.

The Case for Routine CYP2C19 ( Plavix® ) Genetic Testing

Antithrombotic strategies in patients on long-term oral anticoagulation therapy undergoing percutaneous coronary intervention. ACS: acute coronary syndrome;

A model of variation and accelerating factors in the process of acute care chain of patients with STEMI going for primary PCI. PCI, percutaneous coronary.

P2Y12 receptor inhibitor therapy for secondary prevention of patients with stable coronary artery disease. P2Y12 receptor inhibitor therapy for secondary.

Cardiovascular Epidemiology and Epidemiological Modelling

Presentation transcript:

PRACTICAL RECOMMENDATIONS ON ANTI- THROMBOTIC TREATMENT IN PATIENTS TREATED WITH DRUG-ELUTING STENTS Giuseppe Biondi-Zoccai Ospedale S. Giovanni Battista “Molinette” Università di Torino Convegno Regionale Piemonte e Valle d’Aosta “La morte improvvisa dal neonato all’adulto: un evento sempre inevitabile?” - Torino, Settembre 2007 (h )

Learning objectives I.Goals of antithrombotic treatment in patients undergoing drug-eluting stenting (DES) II.Pathophysiologic and clinical data on thrombotic risk in patients with DES III.Practical recommendations

Learning objectives I.Goals of antithrombotic treatment in patients undergoing drug-eluting stenting (DES) II.Pathophysiologic and clinical data on thrombotic risk in patients with DES III.Practical recommendations

Learning objectives I.Goals of antithrombotic treatment in patients undergoing drug-eluting stenting (DES) II.Clinical data on thrombotic risk in patients with DES III.Practical recommendations

Benefits of prolonged dual antiplatelet treatement Eisenstein et al, JAMA patients treated with DES: no data on stent thrombosis (ST)

Incidence and predictors of stent thrombosis in DES Iakovou et al, JAMA patients treated with DES: 0.6% subacute ST; 0.7% late ST; 1.3% total ST at 9 months !!!

Is dual antiplatelet therapy truly beneficial beyond 6 months? Airoldi et al, Circulation patients treated with DES: 1.4% ST <6 months; 0.5% ST 6-18 months ; 1.9% total ST at 18 months

Learning objectives I.Goals of antithrombotic treatment in patients undergoing drug-eluting stenting (DES) II.Pathophysiologic and clinical data on thrombotic risk in patients with DES III.Practical recommendations

Resources for practical recommendations I.Grines CL, Bonow RO, Casey DE Jr, et al; American Heart Association; American College of Cardiology; Society for Cardiovascular Angiography and Interventions; American College of Surgeons; American Dental Association; American College of Physicians. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation Feb 13;115(6): II.Hodgson JM, Stone GW, Lincoff AM, et al; Society for Cardiovascular Angiography and Interventions. Late stent thrombosis: considerations and practical advice for the use of drug- eluting stents: a report from the Society for Cardiovascular Angiography and Interventions Drug-eluting Stent Task Force. Catheter Cardiovasc Interv Feb 15;69(3): III.Silber S, Albertsson P, Aviles FF, et al; Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J Apr;26(8): IV.Steinhubl SR, Berger PB, Mann JT 3rd, et al; CREDO Investigators. Clopidogrel for the Reduction of Events During Observation. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA Nov 20;288(19):

Resources for practical recommendations I.Grines CL, Bonow RO, Casey DE Jr, et al; American Heart Association; American College of Cardiology; Society for Cardiovascular Angiography and Interventions; American College of Surgeons; American Dental Association; American College of Physicians. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation Feb 13;115(6): II.Hodgson JM, Stone GW, Lincoff AM, et al; Society for Cardiovascular Angiography and Interventions. Late stent thrombosis: considerations and practical advice for the use of drug- eluting stents: a report from the Society for Cardiovascular Angiography and Interventions Drug-eluting Stent Task Force. Catheter Cardiovasc Interv Feb 15;69(3): III.Silber S, Albertsson P, Aviles FF, et al; Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J Apr;26(8): IV.Steinhubl SR, Berger PB, Mann JT 3rd, et al; CREDO Investigators. Clopidogrel for the Reduction of Events During Observation. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA Nov 20;288(19): m of ASA+TNP 12m of ASA+TNP 6-12m of ASA+TNP 12m of ASA+TNP ASA=aspirin; TNP=thienopyridine (clopidogrel or ticlopidine)

66-y-o woman with effort angina PTCA with non-overlapping bare- metal stents in right coronary artery

Optimal antithrombotic Rx? Life-long aspirin Life-long aspirin, TNP for 1 month Life-long aspirin, TNP for >6-12 months Life-long aspirin, TNP for months TNP=thienopyridine (clopidogrel or ticlopidine)

Optimal antithrombotic Rx? Life-long aspirin Life-long aspirin, TNP for 1 month Life-long aspirin, TNP for >6-12 months Life-long aspirin, TNP for months TNP=thienopyridine (clopidogrel or ticlopidine)

58-y-o man with silent ischemia PTCA with multiple small diameter paclitaxel-eluting stents in distal right coronary branches

Optimal antithrombotic Rx? Life-long aspirin Life-long aspirin, TNP for 1 month Life-long aspirin, TNP for >6-12 months Life-long aspirin, TNP for months TNP=thienopyridine (clopidogrel or ticlopidine)

Optimal antithrombotic Rx? Life-long aspirin Life-long aspirin, TNP for 1 month Life-long aspirin, TNP for >6-12 months Life-long aspirin, TNP for months TNP=thienopyridine (clopidogrel or ticlopidine)

71-y-o woman with unstable angina PTCA with sirolimus-eluting stents in unprotected distal left main and proximal left anterior descending

Optimal antithrombotic Rx? Life-long aspirin Life-long aspirin, TNP for 1 month Life-long aspirin, TNP for >6-12 months Life-long aspirin, TNP for months TNP=thienopyridine (clopidogrel or ticlopidine)

Optimal antithrombotic Rx? Life-long aspirin Life-long aspirin, TNP for 1 month Life-long aspirin, TNP for >6-12 months Life-long aspirin, TNP for months TNP=thienopyridine (clopidogrel or ticlopidine)

56-y-o man with de novo ST- elevation myocardial infarction PTCA with bare-metal stent in mid left anterior descending

Optimal antithrombotic Rx? Life-long aspirin Life-long aspirin, TNP for 1 month Life-long aspirin, TNP for >6-12 months Life-long aspirin, TNP for months TNP=thienopyridine (clopidogrel or ticlopidine)

Optimal antithrombotic Rx? Life-long aspirin Life-long aspirin, TNP for 1 month Life-long aspirin, TNP for >6-12 months Life-long aspirin, TNP for months TNP=thienopyridine (clopidogrel or ticlopidine)

Take home messages

1. Not all patients are born equal

2. Both accurate choice of revascularization strategy (CABG, PCI with BMS, PCI with DES, or none) AND aggressive medical RX are pivotal

3. Avoid aggressive and long-term dual antiplatelet therapy for all patients, as every single one should be handled differently All from All different

More humbly… DIAGNOSISPCITHERAPY CSA -Life-long aspirin POBALife-long aspirin BMSLife-long aspirin, TNP for 1 month DESLife-long aspirin, TNP for >6-12 months NSTEACS -Life-long aspirin, TNP for months POBALife-long aspirin, TNP for months BMSLife-long aspirin, TNP for months DESLife-long aspirin, TNP for months STEMI -Life-long aspirin, TNP for 1 month POBALife-long aspirin, TNP for 1 month BMSLife-long aspirin, TNP for 1 month DESLife-long aspirin, TNP for >6-12 months BMS=bare-metal stent; CSA=chronic stable angina; DES=drug-eluting stent; NSTEACS=non-ST-elevation acute coronary syndromes; PCI=percutaneous coronary intervention; POBA=pure-only balloon angioplasty; STEMI=ST-elevation myocardial infarction; TNP=thienopyridine (clopidogrel or ticlopidine)

For further slides on these topics please feel free to visit the metcardio.org website: