Dauer der doppelten Plättchenhemmung nach AMI / Stent

Transcription

1 Dauer der doppelten Plättchenhemmung nach AMI / Stent Kardio-Lunch Christoph Kaiser Universitätsspital Basel Christoph.kaiser@usb.ch

2 DAPT after Stenting 257 patients with PCI & stent: ASS & Ticlopidin vs. Marcoumar & Heparin & ASS Primary endpoint: cardiac death, MI, CABG, TVR < 30 days Schömig A, et al. N Engl J Med 1996;

3 DAPT after Stenting mostly stable patients with PCI & stent Primary endpoint: death, TLR, stent thrombosis, MI < 30 days Leon M; N Engl J Med 1998;

4 DAPT after Stenting mostly stable patients with PCI & stent Primary endpoint: death, TLR, stent thrombosis, MI < 30 days Leon M; N Engl J Med 1998;

5 DAPT and ACS CURE-Trial: patients with NSTEMI-ACS; ASS & Clopidogrel vs ASS & Placebo over 12 months 11.4% 9.3% 20% RRR P < CURE-Investigators, N Engl J Med. 2001;345:

6 Long-Term DAPT after Stenting CREDO-Trial: patients with elective stenting: ASS and Clopidogrel vs ASS and Placebo over 12 months Steinhubl SR et al. JAMA 2002;288:

7 DAPT in high-risk patients? CHARISMA: with cv-disease or multiple risk factors: Clopidogrel & ASS versus ASS alone for 28 months Primary endpoint: composite of MI, stroke or cardiovascular death Bhatt DL, N Engl J Med 2006;354:

8 DAPT in high-risk patients? CHARISMA: with cv-disease or multiple risk factors: Clopidogrel & ASS versus ASS alone for 28 months Primary endpoint: composite of MI, stroke or cardiovascular death Bhatt DL, N Engl J Med 2006;354:

9 DAPT in high-risk patients? CHARISMA: with cv-disease or multiple risk factors: Clopidogrel & ASS versus ASS alone for 28 months Primary endpoint: composite of MI, stroke or cardiovascular death P=0.22% Bhatt DL, N Engl J Med 2006;354:

10 DAPT in high-risk patients? CHARISMA: with cv-disease or multiple risk factors: Clopidogrel & ASS versus ASS alone for 28 months Primary endpoint: composite of MI, stroke or cardiovascular death Bhatt DL, N Engl J Med 2006;354:

11 DAPT for 12 Months After ACS and DES

12 2005: ACC & ESC DES - Firestorm Bern-Rotterdam registry: n=8 146, PES and SES 0,6% per year Daemen J, et al. Lancet 2007;369:667-78

13 Time Course of bleeding under DAPT CHARISMA: with cv-disease or multiple risk factors: Clopidogrel & ASS versus ASS alone for 28 months Bleeding 0-12 months Bleeding months Berger P et al. Circulation 2010;121:

14 The threat of late/very late stent thrombosis Mauri L, et al. Am Heart J 2010;160:

15 From 2005: Introduction of 2nd generation DES 1st generation DES: Taxus Cypher no more available!!!! 2nd generation DES: Endeavor Family Xience Family Orsiro Nobori Biomatrix Family.

16 What s different in 2nd generation DES?? New platforms and alloys (Cobalt-chromium, thinner struts) New drugs (Everolimus, Biolimus, Zotarolimus, no Paclitaxel) Less drugs, different release-kinetics New polymers, biodegradable polymers Progress in implantation techniques

17 The effect of 2nd generation DES and Time

18 Stent thrombosis with 2nd generation DES Single center: n=3 844 Metaanalysis, n= Dores H, et al. J Invasive Cardio. 2013;25:330-6 Philip, F, et al. Circ Cardiovasc Interv 2014;7:49-61

19 DAPT-duration after elective stenting PODIGRY: 6 versus 12 month DAPT after coronary stenting (n= 1 970) Primary Endpoint: composite death, MI and stroke Pirmary EP Death ST MI Stroke Valgimigli M, et al. Circulation 2012;125:

20 DAPT-duration after elective stenting 2014 ESC-Guidelines on myocardial revascularization

21 AHA The opposite: Extension of DAPT-duration after stenting

22 Extension of DAPT-duration after stenting Mauri L, et al. N Engl J Med 2014;371:

23 Extension of DAPT-duration after stenting Mauri L, et al. N Engl J Med 2014;371:

24 Extension of DAPT-duration after stenting 75% elective Mauri L, et al. N Engl J Med 2014;371:

25 Extension of DAPT-duration after stenting Mauri L, et al. N Engl J Med 2014;371:

26 Extension of DAPT-duration after stenting Mauri L, et al. N Engl J Med 2014;371:

27 Extension of DAPT-duration after stenting Mauri L, et al. N Engl J Med 2014;371:

28 Extension of DAPT-duration after stenting

29 Extension of DAPT-duration after stenting My personal conclusions: Patients after coronary stenting remain at high risk for ischemic events DAPT: Effect of DAPT >1 year is due to a) first generation DES used and b) successful secondary prevention in high-risk subsets The benefit of DAPT > 1year is tempered by an increase in bleeding events (relative increase 61%)

30 ESC 2015 Extension of DAPT-duration after MI due to introduction of 2nd generation Thioenopyridines

31 2nd generation Thioenopyridines n= n= Wiviott S et al. N Engl J Med 2007;357: Wallentin L et al. N Engl J Med 2009:361:1-13

32 Extension of DAPT-duration after MI REACH-Registry: n= > 45 years old: 4 year outcomes Bhatt DL, et al. JAMA 2010;304:1350-7

33 Extension of DAPT-duration after MI CHARISMA: Clopidogrel & ASS versus ASS alone for 28 months post-hoc exploratory subgroup with prior MI without prior MI Bhatt DL at al. J Am Coll Cardiol. 2007;49:

34 Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372:

35 Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372:

36 Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372:

37 Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372:

38 Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372:

39 Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372: Prof. D. Trenk, Herzzentrum Bad Krozingen

40 Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372:

41 Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372: Prof. D. Trenk, Herzzentrum Bad Krozingen

42 Extension of DAPT-duration after MI My personal conclusions: Patients after myocardial infarction remain at high risk for ischemic events Long-term DAPT with Ticagrelor & ASS reduce the risk of CV-death, MI or stroke in high-rsik patients after myocardial infarction Long-term DAPT with Ticagrelor & ASS increases the risk of major bleeding The two doses of Ticagrelor had similar overall efficacy, but bleeding and other side effects tended to be less frequent with 60mg bid po

43 Near future I: Guideline Update

44 Near future II: Rather Mono than Bi

45 Besten Dank für Ihre Aufmerksamkeit!

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