Gestione della DAPT post-pci in chirurgia cardiaca e non cardiaca

Transcription

1 Gestione della DAPT post-pci in chirurgia cardiaca e non cardiaca Francesco Saia Polo Cardio-Toraco-Vascolare Azienda Ospedaliero-Universitaria di Bologna Policlinico S. Orsola Malpighi Bologna

2 DISCLOSURE INFORMATION Francesco Saia negli ultimi due anni ho avuto i seguenti rapporti anche di finanziamento con soggetti portatori di interessi commerciali in campo sanitario: Advisory Board: Astra Zeneca, Daiichy-Sankyo, Bayer, Boehringer-Ingelheim, Medtronic, Abbott Vascular, Amgen, St. Jude Relazioni a congressi: Astra Zeneca, Daiichy-Sankyo, Bayer, Abbott Vascular, Menarini, Servier, Volcano, Boston Scientific, Edwards

3 How frequent is surgery after coronary stenting? patients with previous coronary stenting, patients underwent surgical procedures Saia F et al. Circ Cardiovasc Qual Outcomes. 2016;9:39-47

4 Type of surgery after coronary stent General surgery 01% 00% 20% 19% Orthopedic Urologic 02% 02% 02% 14% Vascular Ophthalmology Neurosurgery 03% 05% 06% 11% Dermatology Otolaryngology Plastic surgery 07% 09% Thoracic Gynecological Maxillofacial Dentistry Cardiac surgery Saia F et al. Circ Cardiovasc Qual Outcomes. 2016;9:39-47

5 Aspirin continuation increased the rate of bleeding complications by factor 1.5 (median, interquartile range: ), it did not lead to a higher level of the severity of bleeding complications (exception: intracranial surgery, and possibly transurethral prostatectomy) Aspirin withdrawal precedes up to 10.2% of acute cardiovascular syndromes. The time interval between discontinuation and acute coronary syndromes was 8.5 ± 3.6 days Burger W et al. Journal of Internal Medicine 2005; 257:

6 Surgery is #1 cause of DAPT discontinuation 1358 consecutive pts treated with DES and discharged on dual antiplatelet therapy with aspirin (100 mg/day) and clopidogrel (75 mg/day) Clopidogrel was to be maintained for 12 months Pts were followed-up for 32.4±11.3 months 8,8% 4,8% Discontinuation Causes: 86,4% Surgery 34.5% Bleeding 21% Medical decision 17.6% Dental interventions 7.6% Economic/burocratic reasons 5.9% Anticoagulant therapy 5.0% No discontinuation Early discontinuation Late discontinuation Rossini R et al. Am J Cardiol 2011;107:

7 Surgery is #1 cause of DAPT discontinuation % Patients who discontinued antiplatelet therapy had a higher incidence of death, MACE and stent thrombosis MACE Rossini R et al. Am J Cardiol 2011;107:

8 Timing of DAPT discontinuation after stent and MACE Rossini R et al. Am J Cardiol 2011;107:

9 Timing of surgery after coronary stent <30 days 30d - 6m 6-12 m m m m m Saia F et al. Circ Cardiovasc Qual Outcomes. 2016;9:39-47

10 Rates and types of urgent surgery after stent Saia F et al. Circ Cardiovasc Qual Outcomes. 2016;9:39-47

11 Bridging therapy Capodanno D, Angiolillo DJ. Circulation. 2013;128:

12 Stent thrombosis risk at the time of surgery Saia F et al. Circ Cardiovasc Qual Outcomes. 2016;9:39-47

13 New DES vs. first generation DES Stefanini G et al. Circ Cardiovasc Intvn. 2012;5:332-5

14 LEADERS Free Urban P et al. N Engl J Med. 2015;373:

15 The concept of global ischemic risk Risk factors (eg diabetes) Clinical characteristics (eg ACS) Angiographic characteristic (eg MVD) Generic surgical risk (pro-thrombotic) Intrinsic surgical risk Urgency Stent type (BMS, odes, ndes) Time from PCI to surgery PCI procedure complexity

16 The concept of surgery-specific haemorragic risk

17 What guidelines say Kristensen SD et al. Eur Heart J 2014

18 What guidelines say Kristensen SD et al. Eur Heart J 2014

19 What guidelines say AHA/ACC Fleisher LA, et al. Circulation 2014

20 DOCUMENTO DI POSIZIONE Stent, Terapia Antiaggregante e Chirurgia

21 Rossini R et al EuroIntervention. 2014;10:38-46.

22 Rossini et al EuroIntervention. 2014;10:38-46.

23 Rossini et al EuroIntervention. 2014;10:38-46.

24 Surgery and stent (SAS) registry Adherence to consensus recommendations occurred in 85% of the cases. Perioperative aspirin and dual antiplatelet therapy were maintained in 69.7 and 10.5% of the cases, respectively Rossini R et al. Cath Cardiovasc Intvn 2017;89:E13 E25

25 Stent and surgery app

26 Ischemic and bleeding risks at the time of surgery Saia F et al. Circ Cardiovasc Qual Outcomes. 2016;9:39-47

27 Ischemic and bleeding risks at the time of surgery Cardiac death 2.5%; MI 1.5%; serious bleeding event 6.4% Saia F et al. Circ Cardiovasc Qual Outcomes. 2016;9:39-47

28 Ischemic and bleeding risks at the time of surgery Saia F et al. Circ Cardiovasc Qual Outcomes. 2016;9:39-47

29 Ischemic and bleeding risks at the time of surgery Saia F et al. Circ Cardiovasc Qual Outcomes. 2016;9:39-47

30

31 Surgery and stent (SAS) 2

32 Conclusions Surgery is very frequent in patients with coronary stents (40% at 5 years) Surgery after stents increases the risk of thrombotic events and the risk is inversely related to time from PCI to surgery ( delay elective surgery) Surgery is #1 cause of premature DAPT discontinuation ( caveat) Ongoing antiplatelet treatment in patients undergoiong surgery is associated with increased bleeding risk ( case-by-case evaluation) Aspirin continued in most procedures ( notable exceptions neurosurgery, urologic surgery) Need for a consensus decision ( utility of Consensus Documents)