antiplatelet and anti-thrombotic therapy...therapy (the triple threat) outline • anti-thrombotic...
TRANSCRIPT
Ivan Anderson, MDRIHVH Cardiology
Antiplatelet and Anti-Thrombotic
Therapy
Outline
• Anti-thrombotic therapy– Risk stratification of stroke with atrial fibrillation– DVT and PE treatment– Pharmacology
• Anti-platelet therapy– Pharmacology of PGY-12 antagonists– Risk of premature discontinuation of dual anti-platelet
therapy• Combination of anti-thrombotic and anti-platelet
therapy (the triple threat)
Outline
• Anti-thrombotic therapy– Risk stratification of stroke with atrial fibrillation– DVT and PE treatment– Pharmacology
• Anti-platelet therapy– Pharmacology of PGY-12 antagonists– Risk of premature discontinuation of dual anti-platelet
therapy• Combination of anti-thrombotic and anti-platelet
therapy (the triple threat)
https://www.chadsvasc.org
Dosing
Treatment Doses Deep Venous Thrombosis and Pulmonary Embolism
• Pradaxa: 150 mg PO BID (same)• Xarelto: 15 mg PO BID x 21 days
– Then as per previous slide
• Eliquis: 10 mg PO BID x 7 days– Then as per previous slide
Europace (2013) 15, 625–651
Take Xarelto with food
RELY Data (Pradaxa vs Warfarin)
ROCKET-AF Data (Xarelto vs Warfarin)
ARISTOTLE Data (Eliquis vs Warfarin)
Package Insert Apixaban – Now Removed
Outline
• Anti-thrombotic therapy– Risk stratification of stroke with atrial fibrillation– DVT and PE treatment– Pharmacology
• Anti-platelet therapy– Pharmacology of PGY-12 antagonists– Risk of premature discontinuation of dual anti-platelet
therapy• Combination of anti-thrombotic and anti-platelet
therapy (the triple threat)
Outline
• Anti-thrombotic therapy– Risk stratification of stroke with atrial fibrillation– DVT and PE treatment– Pharmacology
• Anti-platelet therapy– Pharmacology of PGY-12 antagonists– Risk of premature discontinuation of dual anti-platelet
therapy• Combination of anti-thrombotic and anti-platelet
therapy (the triple threat)
Acute Coronary Syndromes.
Ezra A. Amsterdam et al. Circulation. 2014;130:e344-e426
An Activated Platelet
Platelet Activation
Central Role of P2Y12 Receptor in Thrombus Propogation
J Clin Invest. 2004 Feb 1; 113(3): 340–345
Schömig A. N Engl J Med 2009;361:1108-1111.
Biotransformation and Mode of Action of Clopidogrel, Prasugrel, and Ticagrelor.
Summary of Recommendations for Initial Antiplatelet/Anticoagulant Therapy in Patients With Definite or Likely NSTE-ACS and PCI.
Ezra A. Amsterdam et al. Circulation. 2014;130:e344-e426
Summary of Recommendations for Initial Antiplatelet/Anticoagulant Therapy in Patients With Definite or
Likely NSTE-ACS and PCI.
• Addition of Plavix or Ticagrelor is Class 1 Level of Evidence B for early care of Non-ST Elevation Acute Coronary Syndrome
Ezra A. Amsterdam et al. Circulation. 2014;130:e344-e426
The Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. N Engl J Med 2001;345:494-502.
Cumulative Hazard Rates for the First Primary Outcome (Death from Cardiovascular Causes, Nonfatal Myocardial Infarction, or Stroke) during the 12
Months of the Study.
~600% Increased Risk of Stent Thrombosis Stopping DAPT after BMS
Circulation. 2007;115:813-818 (DAPT = Dual Anti-Platelet Therapy, BMS – Bare Metal Stent)
Am J Cardiol 2006;98:352–356
Stent Related Risk Factors for InstentThrombosis
• Bifurcation stenting• Eccentric stenosis• Long stents (e.g. 26 or 30 mm)• Tortuous artery
STEMI After Premature Discontinuation of Anti-Platelet Therapy
JACC Vol. 35, No. 5, 2000
A Few Notes on Effient (prasugrel) and Brilinta (ticagrelor)
• Effient (prasugrel): black box warning – do not use if prior stroke
• Brilinta (ticagrelor)– Often may cause dyspnea– Can lead to bradyarrhythmias
Outline
• Anti-thrombotic therapy– Risk stratification of stroke with atrial fibrillation– DVT and PE treatment– Pharmacology
• Anti-platelet therapy– Pharmacology of PGY-12 antagonists– Risk of premature discontinuation of dual anti-platelet
therapy• Combination of anti-thrombotic and anti-platelet
therapy (the triple threat)
Outline
• Anti-thrombotic therapy– Risk stratification of stroke with atrial fibrillation– DVT and PE treatment– Pharmacology
• Anti-platelet therapy– Pharmacology of PGY-12 antagonists– Risk of premature discontinuation of dual anti-platelet
therapy• Combination of anti-thrombotic and anti-
platelet therapy (the triple threat)
WOEST Trial
• Randomized control trial of double versus triple therapy after PCI– Double therapy: Plavix + Coumadin– Triple therapy: Aspirin + Plavix + Coumadin
• Primary Endpoint: any bleeding
Lancet 2013; 381: 1107–15
WOEST Trial (Death and Stent Thrombosis)
Lancet 2013; 381: 1107–15
PIONEER AF-PCI Trial
• Randomized control trial of anti-coagulation strategies with non-valvular A fib
• 2124 Patients randomized 1:1:1 to 3 groups– Group 1: Xarelto 15 mg + P2Y12 inhibitor x 12 mo– Group 2: Xarelto 2.5 mg + DAPT for 1, 6 or 12 mo– Group 3: Coumadin + DAPT for 1, 6 or 12 mo
(DAPT = Dual Anti-Platelet Therapy)
Gibson CM et al. N Engl J Med 2016;375:2423-2434.
Gibson CM et al. N Engl J Med 2016;375:2423-2434.
Stratification, Randomization, and Follow-up.
Gibson CM et al. N Engl J Med 2016;375:2423-2434.
Cumulative Incidence of the Primary Safety End Point and a Secondary Efficacy End Point.
10 Endpoint: Bleeding
2nd Endpoint: Cardiovascular Death, MI, CVA
Group 1: Xarelto 15 mg + P2Y12 inhibitor x 12 mo
Group 2: Xarelto 2.5 mg + DAPT for 1, 6 or 12 mo
Group 3: Coumadin + DAPT for 1, 6 or 12 mo
Questions
Eikelboom JW et al. N Engl J Med 2017;377:1319-1330.
Cumulative Incidence of the Primary Efficacy Outcome among Participants Receiving Rivaroxaban plus Aspirin, Rivaroxaban
Alone, or Aspirin Alone.