doppia antiaggregazione dopo impianto di des: prolungata... ma non troppo? doppia antiaggregazione...
TRANSCRIPT
Doppia antiaggregazionedopo impianto di DES:
prolungata... ma non prolungata... ma non troppo?troppo?
Doppia antiaggregazionedopo impianto di DES:
prolungata... ma non prolungata... ma non troppo?troppo?
UO Cardiologia
ASL 9 Grosseto
UO Cardiologia
ASL 9 GrossetoUgo LimbrunoUgo Limbruno
Conflict of Interest: cConflict of Interest: consulting for ABBOTT, CORDIS, BOSTON SCIENTIFIC, TERUMO, BIOTRONIK, PFIZER, ANGELINI, ASTRA ZENECA, TMC, IROKO. Conflict of Interest: cConflict of Interest: consulting for ABBOTT, CORDIS, BOSTON SCIENTIFIC, TERUMO, BIOTRONIK, PFIZER, ANGELINI, ASTRA ZENECA, TMC, IROKO.
risk
ST without DAPT
bleeds with DAPT
time after DES
1 mo 3 mo 6 mo 1 year
DAPT durationDAPT duration
• NEJM 2010;362:1374
• Heart 2009;95:1579
DAPT durationDAPT duration
current practice
??
??
DAPT durationDAPT duration
528 pts
IntentionalIntentionalDAPT withdrawal
IntentionalIntentionalDAPT withdrawal
UnplannedUnplannedDAPT withdrawal
UnplannedUnplannedDAPT withdrawal
≠≠
0.3%/year
0.3%/year
IntentionalIntentionalDAPT withdrawal
UnplannedUnplannedDAPT withdrawal≠≠
fre
ed
om
fro
m S
T (
%)
3-6%
/year
Mauri et al. N Engl J Med 2007;356:1020 Roy et al. Am J Cardiol 2009;103:801Kimura et al. Circulation 2009;119:987
Bleeding
Surgery
Peptic ulcer
Bleeding
Surgery
Peptic ulcer70%!70%!
Latib et al, Am J Cardiol 2008;102:1477–1481
Reasons for premature Reasons for premature DAPTDAPT discontinuation discontinuation
Bleeding
Surgery
Peptic ulcer
Bleeding
Surgery
Peptic ulcer70%!70%!
Latib et al, Am J Cardiol 2008;102:1477–1481
Reasons for premature Reasons for premature DAPTDAPT discontinuation discontinuation
Rossini et al, Am J Cardiol 2011;107:186–194
Kimura et al. Circulation 2009;119:987
J-Cypher Registry (10.778 pts)
Only Thienowithdrawal
Only Thienowithdrawal
ASA + ThienoASA + Thienowithdrawalwithdrawal
Eisenberg, et al. Circulation 2009;119:1634
161 161 pts withpts withdefinite STdefinite ST
ASA+Thieno(simultaneous)
ASA+Thieno(sequential)
Thieno only
10 d
ays
10 d
ays
>3
mo
nth
>3
mo
nth
unplannedunplannedDAPT withdrawal
Stent
thrombosis
Bleed, Surgery, Ulcer
ASA + Thieno withdrawalTransfusion, Cancer: “thrombophilic state”
prolongedprolongedDAPT
Kimura et al. Circulation 2009;119:987
J-Cypher Registry (10.778 pts)
6-month landmark analysis
Kimura et al. Circulation 2009;119:987
ACS vsvs Non-ACS
Roy et al. Am J Cardiol 2009;103:801
WHC Registry (2.889 pts)
Clopidogrel treatment duration (days)
Ris
k o
f S
T a
t 4
years
Schulz et al. Eur Heart J 2009;30:2714
6816 pts
Airoldi et al. Circulation 2007;116:145
0.3%/year0.3%/year
2%/y
ear
Stent thrombosis (3021 pts)
BleedingBleeding
Latib et al. Am J Cardiol 2008;102:1477
Latib et al. Am J Cardiol 2008;102:1477
Bleeding & OutcomeBleeding & Outcome
ACC 2011
EXCELLENT trial (1428 pts)EXCELLENT trial (1428 pts)
2013 pts
2013 pts
...tailored...tailored DAPTDAPT duration? duration?
2010guidelines
2010guidelines
DES type&
stent thrombosis
DES type&
stent thrombosis
9-month strut coverage after PPCI (46 pts)
Fan et al. Am J Cardiol 2010;105:972
0
2
4
6
8
10
ZES
% u
ncovere
d s
tru
ts
p=NS
BMS
OCTAMI trial (44 pts)
OCT uncovered struts 6 month after PPCI
Guagliumi, Musumeci et al. JACC Cardiovasc Interv 2010;3:680
BMS
old old -DES
new new -DES
SCAAR registry: stent thrombosisstent thrombosisSCAAR registry: stent thrombosisstent thrombosis
DES for ISR(3-month OCT)
DESERT trialDESERT trial
OCT:6-month
strut coverage
Population Protocol End point Population Protocol End point
DES15 pts with de novode novo lesion
15 pts withISR after BMS
risk
ST without DAPT
bleeds with DAPT
time1 mo 3 mo 6 mo 1 year
DAPT durationDAPT duration
current practice
DAPT durationDAPT duration
Accelerated reendothelizationAccelerated reendothelizationwith 2with 2ndnd generation DES? generation DES?
Maj
or b
leed
ing
(%
)
Sibbing D et al, J Thromb Haemost 2010
Sibbing D et al, J Thromb Haemost 2010
over-respondersmajor bleedings
Response variability to clopidogrelResponse variability to clopidogrel
risk
ST without DAPT
bleeds with DAPT
time1 mo 3 mo 6 mo 1 year
DAPT durationDAPT duration
current practice
DAPT durationDAPT duration
• Over-respondersOver-responders• Haemorrhagic diatesisHaemorrhagic diatesis• Prasugrel, Ticagrelor?Prasugrel, Ticagrelor?
Parodi et al, JAMA 2011; 306:1215-1223.
high
lowresidual
platelet reactivity
1789 ptsp<0.002
Mortality & platelet reactivity after ACSMortality & platelet reactivity after ACSca
rdia
c m
ort
alit
y,
%
ST without DAPTST without DAPT
bleeds with DAPTbleeds with DAPT
• Multiple stenting
• Left main stentingri
sk
time1 mo 3 mo 6 mo 1 year
DAPT durationDAPT duration
current practice
DAPT durationDAPT durationDAPT durationDAPT duration
• Thrombophillic state, low-responders
• Uncovered/malapposed struts at OCT?
Parodi et al, JAMA 2011; in press.
high
lowresidual
platelet reactivity
1789 ptsp<0.002
Mortality & platelet reactivity after ACSMortality & platelet reactivity after ACSca
rdia
c m
ort
alit
y,
%
0
2
4
6
8
10
12
14
16
18
20
card
iac m
ort
ality
, %
thienopyridinedose-adjustmentthienopyridine
dose-adjustment
low high
residual platelet reactivity
P= NS
ConclusioniConclusioniConclusioniConclusioni
Aderenza alla DAPT
cruciale nei primi 30gg!
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
ConclusioniConclusioniConclusioniConclusioni
ConclusioniConclusioniConclusioniConclusioni
...e la durata ottimale DAPT...e la durata ottimale DAPT
con Ticagrelor o Prasugrel?con Ticagrelor o Prasugrel?