interventional cardiology for the non-cardiologist: new ...percutaneous coronary intervention versus...

10/18/2019

1

Interventional Cardiology for the

Non-Cardiologist:

New Innovations and

New Guidelines

Krishan Soni, MD, MBA, FACC

Assistant Professor of Medicine

Division of Cardiology

Disclosures

No Conflicts of Interest

No Financial Disclosures

Credit to Dr. Lucas Zier

(UCSF) for several slides

in this presentation

[email protected]

10/18/2019

2

Prevention

1. Understand the use of aspirin in the prevention of coronary artery disease (CAD)

Stable Ischemic Heart Disease

1. Define the role of percutaneous coronary intervention (PCI) in the management of stable ischemic heart disease

2. Be familiar with contemporary data regarding surgery versus stents for left main and triple vessel disease

3. Updates in dual antiplatelet therapy (DAPT) after coronary stenting procedures

4. Approach to triple therapy in patients requiring antiplatelet and anticoagulant agents

Structural Heart Disease (if time allows)

1. Define the expanding role of Transcatheter Aortic Valve Replacement (TAVR) in the management of aortic stenosis

Objectives

Major Society Guideline Updates 2016-2019

Clinical Trials Published 2016-2019

Interventional Cardiology for the

Non-Cardiologist

Address common questions fromPrimary Care Community

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiMx6qiuPTTAhUmqFQKHe3IDh4QjRwIBw&url=https%3A%2F%2Fcardiovascularnews.com%2Fnew-accaha-report-outlines-10-measures-for-the-prevention-of-sudden-cardiac-death%2F&psig=AFQjCNHHaumixB0qsIB3V2_sg-4IYRzxgQ&ust=1495024991436455

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiWvZbkuPTTAhVmzlQKHRrHBBwQjRwIBw&url=http%3A%2F%2Fwww.thevent.org%2Fhad-a-look-at-nejm-this-week%2F&psig=AFQjCNECoOjzMkhwAXErfBAjA2SCKMf9Tg&ust=1495025075283240

10/18/2019

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ACS: Acute Coronary Syndrome

BMS: Bare Metal Stent

CAD: Coronary Artery Disease

CABG: Coronary Artery Bypass Graft Surgery

DAPT: Dual Antiplatelet Therapy

DES: Drug Eluting Stent

PCI: Percutaneous Coronary Intervention

SIHD: Stable Ischemic Heart Disease

VKA: Vitamin K Antagonist

TAVR: Transcatheter Aortic Valve Replacement

Acronyms

Strength of Guideline Recommendations

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Prevention

1. Aspirin and prevention of coronary artery disease (CAD)


1. Percutaneous coronary intervention (PCI) in the management of stable ischemic heart disease

2. Surgery versus stents for left main and triple vessel disease

3. Dual antiplatelet therapy (DAPT) after coronary stenting

4. Triple therapy in patients requiring antiplatelet and anticoagulant agents

Structural Heart Disease

1. Expanding role of Transcatheter Aortic Valve Replacement (TAVR) in the management of aortic stenosis

Outline

A 55 yo male patient with mild

hypertension on amlodipine sees you for

routine exam. He has no cardiovascular

disease or other risk factors. He asks

“Should I start taking a baby aspirin?”

A. Definitely!

B. Maybe, we don’t have enough data

C. I’m not sure, we need further testing

D. No, the risks outweigh the benefits

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“Should I start taking a baby aspirin?”

A. Definitely!

B. Maybe, we don’t have enough data

C. I’m not sure, we need further testing

D. No, the risks outweigh the benefits

Primary Prevention: Aspirin

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Gaziano JM, Brotons C, Coppolecchia R, et al., on behalf of the ARRIVE Executive Committee. Use of

aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular

disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet 2018;Aug 26:


ARRIVE Trial

Clinical Question:

What is the clinical benefit of 100 mg per day of aspirin in

reducing the risk of cardiovascular death, myocardial

infarction, unstable angina, stroke, or transient ischemic

attack in patients at moderate risk of cardiovascular events

without diabetes?


ARRIVE Trial

Aspirin Placebo p Value

Composite Outcome of Cardiovascular Death, Myocardial

Infarction, Unstable Angina, Stroke, or TIA

4.3% 4.5% p = 0.60

Gastrointestinal Bleeding 0.97% 0.43% p = 0.0007

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ASCEND Trial

Clinical Question:

What is the clinical benefit of 100 mg per day of aspirin in

reducing the risk of vascular death, myocardial infarction, or

stroke/transient ischemic attack in patients with known

diabetes but no history of cardiovascular disease?

The ASCEND Study Collaborative Group. Effects of Aspirin for Primary

Prevention in Persons With Diabetes Mellitus. N Engl J Med 2018;379:1529-39.


ASCEND Trial


Composite Outcome of Cardiovascular Death, Myocardial

Infarction, Stroke, or TIA8.5% 9.6% p = 0.01

Major Bleeding 4.1% 3.2% p = 0.003

Vascular

Events

Better

Bleeding

worse

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ASCEND Trial


ASCEND Trial

Aspirin resulted in a

1.1% absolute risk

reduction in major

adverse

cardiovascular events

Aspirin resulted in a

0.9% absolute

increase in major

bleeding

NNT: 91 NNH: 111

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ASCEND Trial

What about cancer?...


Gastrointestinal Cancer 2.0% 2.0% p = 1

All Cancer 11.6% 11.5% p = 0.98

No Benefit in Reducing Fatal or Non-Fatal Cancer


10/18/2019

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Aspirin and All Cause Mortality in

14 Primary Preventions Trials


An aspirin a day…

Should not routinely be prescribed to patients without

prior cardiovascular events due to a lack of clinical

benefit and/or increased risk of bleeding that offsets

the reduction in cardiovascular events

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2019 AHA/ACC Guidelines


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Prevention

1. Aspirin and prevention of coronary artery disease (CAD)


1. Percutaneous coronary intervention (PCI) in the management of stable ischemic heart disease

2. Surgery versus stents for left main and triple vessel disease

3. Dual antiplatelet therapy (DAPT) after coronary stenting

4. Triple therapy in patients requiring antiplatelet and anticoagulant agents


1. Expanding role of Transcatheter Aortic Valve Replacement (TAVR) in the management of aortic stenosis

Outline

Stable Ischemic Heart Disease:

Prognosis

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The problem with coronary

revascularization…


Fractional Flow Reserve (FFR) and

Physiologic Guided PCI

FFR tests for:

1.Objective ischemia

2.Viability


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Xaplanteris P, Fournier S, Pijls NH, et al., on behalf of the FAME 2

Investigators. Five-Year Outcomes With PCI Guided by Fractional Flow

Reserve. N Engl J Med 2018;379:250-9.

Stable Ischemic Heart DiseaseFAME 2

Clinical Question:

What is the clinical benefit of percutaneous coronary

intervention in reducing the risk of death, myocardial

infarction, or urgent revascularization in patients with

stable ischemic heart disease and at least one

hemodynamically significant coronary stenosis?

FFR Guided PCI plus Medical

TherapyMedical Therapy

p Value

Composite Outcome of Death, Myocardial

Infarction, or Urgent Revascularization

13.9% 27% p < 0.001

Components of Primary End Point• Death• Myocardial Infarction• Urgent Revascularization

5.1%8.1%6.3%

5.2%12.0%21.1%

Not SignificantBorderlineSignificant


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What about angina?…

Results: Quality of Life% of Patients with Class II-IV Angina at each Time Point

% w

ith

CC

S I

I-IV

An

gin

a


Physiologic (i.e. FFR) guided PCI…

Reduces the composite risk of

death/myocardial infarction/urgent

revascularization and the severity of angina

compared to medical therapy alone in patients

with stable ischemic heart disease

In 2019, coronary physiology

(demonstrating objective ischemia)should be used to guide the decision for PCI

in stable coronary artery disease


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Prevention









Objectives

Thuijs DJFM, Kappetein AP, Serruys PW, et al. SYNTAX Extended Survival Investigators.

Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-

vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised

controlled SYNTAX trial. Lancet 2019;Sep 2


Syntaxes Trial

Clinical Question:

What is the long term (10 year) mortality benefit of bypass

surgery (CABG) vs coronary stenting (PCI) in patients with

severe three vessel or left main disease?

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All Cause Mortality at 10 Years

PCIn = 903

CABGn = 897

HR (95% CI)

All Patients 244 211 1.17(0.97-1.41)

Left Main Disease 93 98 0.90(0.68-1.20)

Three Vessel Disease 151 113 1.41 (1.10-1.80)


Syntaxes Trial

Patients who do better

with CABG

PCI and CABG

“equivalent”

• Three vessel disease

• Complex Anatomy

• Diabetes

• Left Main Disease

Stone GW, et al. Five Year Outcomes after PCI or CABG for Left

Main Coronary Disease. NEJM 2019;Sep 28


Excel Trial

Clinical Question:

What is the long term (5 year) benefit (death, stroke,

myocardial infarction) of bypass surgery (CABG) vs coronary

stenting (PCI) in patients with left main disease?

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5 Year Outcome PCIn = 903

CABGn = 897

CI

Death, Stroke or MI 22% 19.2% [-0.9 to 6.5]

Death from any cause 13.0% 9.9% [0.2 to 6.1]

Definite cardiovascular death

5.0% 4.5% [-1.4 to 2.5]

Myocardial infarction 10.6% 9.1% [-1.3 to 4.2]

Cerebrovascular events 3.3% 5.2% [-2.4 to 0.9]

Ischemia driven revascularization

16.9% 10.0% [3.7 to 10]


Excel Trial

Takeaway: In patients with left main coronary artery disease of low or

intermediate anatomical complexity, there was no significant difference

between PCI and CABG with respect to the rate of the composite outcome of

death, stroke, or myocardial infarction at 5 years.

Physiology guided PCI (FFR) reduces the risk of death/ myocardial infarction/urgent revascularization and the severity of angina compared to medical therapy alone in patients with stable ischemic heart disease

For patients with left main coronary artery disease, PCI and CABG offer similar long term mortality benefits, though cerebrovascular events are higher after CABG and need for coronary revascularization is higher after PCI

For patients with triple vessel coronary artery disease, CABG remains superior


Summary

10/18/2019

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Prevention









Objectives

Current recommendations for

antiplatelet therapy in patients

with CAD

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Aspirin dosing in patients with

Coronary Artery Disease

Higher doses of aspirin are associated with

bleeding and no increased anti-ischemic benefit

When used with ticagrelor, aspirin doses of >100

mg are contraindicated.

Duration of dual antiplatelet therapy

(DAPT)

Duration of DAPT depends on:

Underlying condition

Treatment provided

Stable Ischemic Heart

Disease (SIHD)

Acute Coronary Syndromes

(ACS)

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(DAPT) in patients with ACS

ACS = 1 year

Stopping

early

at 6 months

Acute Coronary

Syndromes (ACS)


(DAPT) in patients with SIHD

PCI with

Bare

Metal

Stent

(BMS)

1 MONTH

PCI with

Drug

Eluting

Stent (DES)

6 MONTHS

Stable Ischemic Heart

Disease (SIHD)

Stopping

early

at 3 months

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Oral Antiplatelet Agents

Aspirin Clopidogrel Prasugrel Ticagrelor

Indication ACSPost PCI

Stroke PVD

ACSPost PCI

StrokePVD

Post PCI ACSPost PCI

DoseLoadMaintenance

325 mg81 mg DAILY

300-600 mg75 mgDAILY

60 mg10 mgDAILY

180 mg90 mg

BID

Class NSAID 2nd gen thienopyridine

(PRODRUG)

2nd genthienopyridine

(PRODRUG)

CTPT

Mechanism IRREVERSIBLECOX 1

IRREVERSIBLE P2Y12

IRREVERSIBLE P2Y12

REVERSIBLE P2Y12

Peak Effect 1-3 hours 6 hours 4 hours 2 hours

CYP Metabolism

NA 2C19 3A4 3A4/5

FDA Approval 1997 2009 2011

Generic Approved 2017 9/2018

Mehran R, et al. Ticagrelor with or without Aspirin in High-Risk

Patients after PCI. NEJM 2019;Sep 26

Duration of Antiplatelet Therapy

TWILIGHT Trial

Clinical Question:

Can aspirin be safely discontinued from the dual

antiplatelet regimen after three months in patients

undergoing PCI?

Regimen:

Aspirin 81 +

Ticagrelor x 12

months

OR

Aspirin 81+

ticagrelor x 3

months, then

ticagrelor + placebo

x 9 months

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ASA + Ticagrelor

(12 months)

ASA (3 mos)Ticagrelor

(12 months)

HRP-value

Bleeding 7.1% 4.0% 0.56P<0.001

Composite • Death (any cause)• Nonfatal MI • Nonfatal stroke

3.9% 3.9% 0.99P <0.001

(non-inferiority)

Bleed

in

g

Co

mp

osite

Duration of Antiplatelet Therapy

TWILIGHT Trial

Antiplatelet Therapy Summary

When used, dose of Aspirin for all patients with CAD is 81 mg daily

Duration of DAPT:

ACS Patients: 1 YEAR for ALL (with/without stent)

SIHD (Stable Ischemic Heart Disease) Patients:

Drug Eluting Stent (DES): 6 MONTHS

Bare Metal Stent (BMS): 1 MONTH

Stopping Early:

New trials show that shorter durations of aspirin therapy after stenting may be effective and result in lower bleeding risk

10/18/2019

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Prevention









Objectives

Long-term treatment with oral anticoagulants is necessary in patients with:

Mechanical heart valves

Many with atrial fibrillation

20–30% of these patients have concomitant ischemic heart disease that requires PCI with stenting and subsequent antiplatelet therapy.

The combination of oral anticoagulants and antiplatelets is associated with a high annual risk (4–16%) of fatal and non-fatal bleeding episodes.

Triple Therapy: The conundrum

Dewilde, Lancet 2013

10/18/2019

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A. B. C. D. E. F.

17% 17% 17% 17% 17% 17%

A 65 yo M presents to the clinic. He had a myocardial

infarction 10 days ago, and was treated with PCI,

aspirin and clopidogrel. An EKG reveals that he is

now in atrial fibrillation. CHADS2Vasc score is 3.

What regimen do you recommend?

A. Aspirin + Clopidogrel(No change)

B. Aspirin + Clopidogrel + Coumadin

C. Aspirin + Ticagrelor + Coumadin

D. Clopidogrel + Coumadin

E. Clopidogrel + Rivaroxaban

F. That’s a hard choice!

What is the indication for triple therapy?

▪ Recent ACS (<1 year)

▪ Recent PCI (< 6 months)

▪ Chronic Ischemic heart

disease

▪ Stroke

▪ Peripheral vascular disease

Dual Antiplatelet (DAPT) Anticoagulation

▪ Atrial fibrillation

▪ Mechanical heart valves

▪ Deep venous thrombosis

▪ Pulmonary embolism

▪ Other indications

▪ Need to balance risk of thrombotic / ischemic events with

bleeding

▪ Use risk scores to help assess: ▪ CHADS2VASC for stroke risk in AF

▪ HAS-BLED for bleeding risk

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Multiple medical options for therapy(Non-valvular Afib)

▪ Aspirin

▪ P2Y12 Inhibitors▪ Clopidogrel

▪ Ticagrelor

▪ Prasugrel

Dual Antiplatelet (DAPT) Oral Anticoagulation

▪ Coumadin

▪ Dabigatran

▪ Rivaroxaban

▪ Apixaban

▪ Edoxaban

▪ What is the safety and efficacy of each

medication?

▪ What combinations offer the greatest

reduction in ischemic / thrombotic events?

▪ Which combinations have the lowest

bleeding risk?

Four recent trials:

WOEST (2013)

PIONEER AF (2016)

RE DUAL PCI (2017)

AUGUSTUS (2019)

What’s the update on triple therapy?

Recent studies

WOEST Trial (Lancet 2013)

▪ RCT, Europe, 2008-2011

▪ 573 patients on anticoagulation undergoing PCI

▪ Randomized to:

▪ Double Therapy: Clopidogrel + Coumadin

▪ Triple Therapy: Clopidogrel + Aspirin + Coumadin

Any bleeding at 1 yearIncidence of death, MI, stroke, stent

thrombosis, revascularization

Dewilde, Lancet 2013

44.4%

19.4%

17.6%

11.1%

10/18/2019

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Recent studies

PIONEER AF PCI (NEJM 2016)

▪ RCT

▪ 2124 patients with nonvalvular AF undergoing PCI

▪ Randomized to:

▪ (1) Rivaroxaban 15 mg Daily + P2Y12

▪ (2) Rivaroxaban 2.5 mg BID + Aspirin + P2Y12

▪ (3) Coumadin + Aspirin + P2Y12

Any bleeding at 1 year

Incidence of death, MI, stroke,

stent thrombosis

26.7%

16.8%

~6%

GIbson, NEJM 2016


Recent studies

REDUAL PCI (NEJM 2017)

▪ RCT

▪ 2725 patients with AF undergoing PCI

▪ Randomized to:

▪ (1) Coumadin + P2Y12 + aspirin

▪ (2) Dabigatran 110 mg BID + P2Y12

▪ (3) Dabigatran 150 mg BID + P2Y12

Major or clinically relevant bleeding at 2 years Incidence of death, MI, stroke, systemic

embolism, unplanned revascularization

25.7%

20.2%

13.7%

13.4%

Cannon, NEJM 2017

10/18/2019

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Summary of recent studies

WOESTCoumadin + Clopidogrel 19% 11%

Coumadin + Clopidogrel + Aspirin 44% 18%

PIONEER AF PCIRivaroxaban 15 mg Daily + P2Y12 17% 6.5%

Rivaroxaban 2.5 mg BID + P2Y12 + Aspirin 18% 5.6%

Coumadin + P2Y12 + Aspirin 27% 6.0%

RE DUAL PCIDabigatran 110 mg BID + P2Y12 15% 13%

Dabigatran 150 mg BID + P2Y12 20% 13%

Coumadin + P2Y12 + Aspirin 26% 14%

Preferred options in U

nited States

What’s the update on triple therapy?New in 2019: AUGUSTUS

AUGUSTUS (NEJM 2019)

▪ RCT, 2x2 factorial design

▪ 4614 patients with AF undergoing PCI

▪ Background: 6 months of P2Y12

▪ Factors:

▪ Apixaban vs. Vitamin K antagonist

▪ Aspirin vs. Placebo

Major or clinically relevant non major bleeding

Lopes, NEJM 2019

Bleeding

Coumadin vs. Apixaban

14.7% vs. 10.5%

Aspirin vs. Placebo

16.1% vs. 9.0%

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What’s the update on triple therapy?AUGUSTUS

Composite of Death or Hospitalization

Lopes, NEJM 2019

TAKEAWAY: In patients with atrial fibrillation and a recent acute

coronary syndrome or PCI treated with a P2Y

12inhibitor, an

antithrombotic regimen that included apixaban, without aspirin,

resulted in less bleeding and fewer hospitalizations without

significant differences in the incidence of ischemic events than

regimens that included a vitamin K antagonist, aspirin, or both.


European Guidelines (2017)

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Key points regarding triple therapy

Recent studies have shown safety and efficacy of:Coumadin + Clopidogrel 75 mg daily

Rivaroxaban 15 mg daily + P2Y12

Dabigatran 150 mg BID + P2Y12

Apixaban + P2Y12

European Guidelines (2017) suggest DOAC

US (Cardiology) Guidelines are still catching up

KEY TAKEAWAYS

If a patient is a candidate for a DOAC, then a DOAC is strongly preferred over Coumadin

No need for triple therapy, can usually drop aspirin

So, what role does aspirin have

in 2019?

10/18/2019

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Doc, Should I still take my aspirin?

Primary Prevention

After Acute Coronary Syndrome (ACS)

Recent MI / PCI < 1 year

ACS + Atrial fibrillation

Chronic Coronary Disease

MI >1 year / PCI >6 mos

Chronic Coronary Disease and Atrial Fibrillation

Not

Routinely

As short

as 3

months

NO

YES

Lifestyle

P2Y

12for 1 Year

Aspirin 3-12 mos

DOAC indefinitely

P2Y

12for one year

Aspirin Alone

Aspirin? Therapy in 2019

YES, but

TBD

DOAC

+/- Aspirin


10/18/2019

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Prevention







Structural Heart Disease (if time allows)


Objectives

0% 0% 0% 0% 0%

An 72 yo man presents to your office with severe

shortness of breath while walking from his bed to

the bathroom. On exam, you hear a 3/6 mid systolic

murmur. Echo shows severe aortic stenosis with

LVEF 55%. What do you recommend?

A. Surgical Aortic Valve Replacement

B. Transcatheter Aortic Valve Replacement

C. Medical Therapy

D. Hospice

E. Ask my local cardiologist

10/18/2019

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• Catheter inserted via femoral,

brachial subclavian artery

• Valve positioned in heart and

delivered under x-ray guidance

Structural Heart Disease: TAVR


Surgical Mortality(STS Prom Risk Calculator)

Frailty Assessment

Major Organ System

Compromise Not

Likely to be Improved

Post procedurally

Procedure Specific

Impediments(ex. Morbid Obesity)

Domains of Aortic Valve Intervention Risk

Assessment...

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2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

ESTI

MA

TED

RIS

KIn

op

era

ble

Hig

hIn

term

edia

te

Low

TIME

PARTNER 1Bn=358 CoreValve ER

n=489

PARTNER 1An=699 CoreValve HR

n=795

SURTAVIn=1746

PARTNER 2A n=2032

NOTIONn=280

NOTION II, Evolut R LR,PARTNER III

Risk Spectrum in TAVR Trials over Time

Structural Heart Disease: Low Risk TAVRPARTNER 3 Trial

Mack, Michael J., et al. "Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve

in Low-Risk Patients." New England Journal of Medicine (2019).

10/18/2019

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Clinical Question:

What is the clinical benefit of TAVR compared with

SAVR in reducing the risk of death from any cause,

stroke, or rehospitalization at one year after the

procedure?



TAVR SAVR p Value

Composite of Death From Any

Cause, Stroke, or

Rehospitalization at 1 Year After

the Procedure

8.5% 15.1% p < 0.001 for Non

Inferiority

p = 0.001 for

Superiority

Key Secondary Endpoints

•New Onset Atrial Fibrillation

•Length of Hospitalization (med)

•Stroke at 30 days

5%

3 days

0.6%

39.5%

7 days

2.4%

p < 0.001

p < 0.001

p = 0.02

10/18/2019

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Structural Heart Disease: TAVR Summary

Transcatheter Aortic Valve Replacement…

Is equivalent to surgical aortic valve replacement in high,

intermediate, and low risk patients with severe aortic

stenosis and may be superior to surgical aortic valve

replacement in low risk patients

10/18/2019

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But…

Structural Heart Disease: TAVR Summary

Long term valve durability

remains unknown especially

in younger patients

Referral to a high volume

center with a

multidisciplinary heart team

remains critical

What have we learned?

Primary Prevention

Aspirin should not routinely be prescribed to patients without prior cardiovascular events


Physiology guided PCI (FFR) reduces risk of urgent revascularization and the severity of angina compared to medical therapy alone

For patients with left main coronary artery disease, PCI and CABG offer similar long term mortality benefits

For patients with triple vessel coronary artery disease, CABG remains superior

10/18/2019

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What have we learned?Dual Antiplatelet Therapy

Guideline based duration of DAPT is currently 12 months after ACS and 6 months after PCI with medicated stents in stable ischemic disease

Dropping aspirin early (at 3 months) may be safe

Triple TherapyDOACs offer lower bleeding risk compared with Coumadin when used in combination with antiplatelet agents

Aspirin can usually be safely dropped when anticoagulation and DAPT are indicated

Structural Heart DiseaseTAVR is equivalent to surgical aortic valve replacement in high, intermediate, and low risk patients with severe aortic stenosis and may be superior to surgical aortic valve replacement in low risk patients

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjsmv353_TTAhVLwWMKHdtOBsQQjRwIBw&url=http%3A%2F%2Fbuzzkenya.com%2Finteresting-questions-ask-people%2F&psig=AFQjCNHC_LieJhZCKl2oaeem-yR2hn3CCg&ust=1495035651157944

10/18/2019

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Thank You!

Questions:

Email Krishan Soni @

[email protected]

415-476-6541


Excel Trial

mailto:[email protected]

10/18/2019

40

Which P2Y12 agent will the cardiologist

recommend?

For Medically Managed ACS

Reasonable to chooseTicagrelor over Clopidogrel

For ACS with PCI

Reasonable to choose Ticagreloror Prasugrel over Clopidogrel

Other pearls regarding P2Y12 inhibitors

Ticagrelor

can cause dyspnea (14%) and bradycardia (6%)

Prasugrel

may be less effective (more bleeding) in patients < 60 kg and > 75 years of age

should not be given until after invasive angiography (Class III)

do not give to patients with a history of TIA or stroke (Class III)

interventional cardiology for the non-cardiologist: new ...percutaneous coronary intervention versus...

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