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

2. risk DAPT duration time after DES?
ST without DAPT
bleeds with DAPT ?
risk
current practice
NEJM 2010;362:1374
Heart 2009;95:1579
DAPT duration
DAPT duration
DAPT duration
1 mo
3 mo
6 mo
1 year
time after DES

3. 528 pts

4. Intentional
DAPT withdrawal ≠
Unplanned
DAPT withdrawal

5. ≠ Intentional Unplanned 3-6%/year 0.3%/year 0.3%/year DAPT withdrawal
freedom from ST (%)
3-6%/year
0.3%/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. 70%! Bleeding Surgery Peptic ulcer
Reasons for premature DAPT discontinuation
Bleeding
Surgery
Peptic ulcer
70%!
Latib et al, Am J Cardiol 2008;102:1477–1481

7. 70%! Bleeding Surgery Peptic ulcer
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. J-Cypher Registry (10.778 pts)
Only Thieno
withdrawal
ASA + Thieno
withdrawal
Kimura et al. Circulation 2009;119:987

9. definite ST 161 pts with ASA+Thieno ASA+Thieno Thieno only >3 month
10 days
ASA+Thieno
(simultaneous)
ASA+Thieno
(sequential)
Thieno only
Eisenberg, et al. Circulation 2009;119:1634

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

11. J-Cypher Registry (10.778 pts)
6-month landmark analysis
Kimura et al. Circulation 2009;119:987

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

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

14. Clopidogrel treatment duration (days)
6816 pts
Risk of ST at 4 years
Clopidogrel treatment duration (days)
Schulz et al. Eur Heart J 2009;30:2714

15. 0.3%/year 2%/year Stent thrombosis (3021 pts) Bleeding
Airoldi et al. Circulation 2007;116:145
Latib et al. Am J Cardiol 2008;102:1477

16. Bleeding & Outcome
Latib et al. Am J Cardiol 2008;102:1477

17. EXCELLENT trial (1428 pts)
ACC 2011

19. 2013 pts

20. 2013 pts

21. 2010
guidelines
...tailored
DAPT duration?

22. DES type
&
stent thrombosis

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

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

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

26. DES for ISR
(3-month OCT)

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

28. Accelerated reendothelization with 2nd generation DES?
ST without DAPT
bleeds with DAPT
risk
current practice
DAPT duration
DAPT duration
1 mo
3 mo
6 mo
1 year
time

29. Response variability to clopidogrel
over-responders
Major bleeding (%)
major bleedings
Dati recenti e preliminari suggeriscono come la valutazione della funzione piastrinica possa essere utile non solo per determinare un’iperreattività piastrinica ma anche un’eccessiva inibizione che potrebbe essere causa di un aumentato rischio di sanguinamento….si apre quindi la possibilità di un futuro uso di questi test per la definizione di una sorta di finestra terapeutica degli agenti antiaggreganti…
Sibbing D et al, J Thromb Haemost 2010
Sibbing D et al, J Thromb Haemost 2010 29

30. Haemorrhagic diatesis Prasugrel, Ticagrelor?
Over-responders
Haemorrhagic diatesis
Prasugrel, Ticagrelor?
ST without DAPT
bleeds with DAPT
risk
current practice
DAPT duration
DAPT duration
1 mo
3 mo
6 mo
1 year
time

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

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

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

34. Aderenza alla DAPT cruciale nei primi 30gg!
Conclusioni
Aderenza alla DAPT
cruciale nei primi 30gg!

35. Conclusioni - pianificata ≠ non pianificata
Sospensione DAPT dopo 30 gg:
- pianificata ≠ non pianificata
- solo thieno ≠ ASA + thieno
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.

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