Prise en charge du SCA en amont de la salle de KT: aspirine seule ou dose de charge d un inhibiteur de la P2Y12?

Transcription

1 Prise en charge du SCA en amont de la salle de KT: aspirine seule ou dose de charge d un inhibiteur de la P2Y12? La Baule Le 17 Mai 2014 Philippe Castellant CHU de Brest, Département de Cardiologie UBO, EA 4324 ORPHY

2 Questions soulevées SCA ST+/ST-? Quel inhibiteur des P2Y12? Si dose de charge: Pourquoi en amont de la salle de KT?

3 Prise en charge du SCA en amont de la salle de KT: aspirine seule ou dose de charge d un inhibiteur de la P2Y12? SCA ST+

4 Aspirine Inhibiteur des P2Y12

5 Composition of Coronary Thrombus in Acute Myocardial Infarction Johanne Silvain et al. Journal of the American College of Cardiology Vol. 57, No. 12, 2011

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7 Addition of clopidogrel to Aspirin and Fibrinolytic Therapy for myocardial Infarction with ST-segment Elevation CLARITY-TIMI 28 MS Sabatine et al. NEJM 2005, vol 352 No.12

8 Cumulative incidence of EP of death from cardiovascular causes, recurrent MI, recurrent ischémia leading to the need for urgent revascularization.

9 Effect of Clopidogrel Pretreatment Before Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction Treated With Fibrinolytics The PCI-CLARITY Study MS Sabatine et al. JAMA, September 14, 2005 Vol 294, No. 10

10 Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. ZM Chen et al. Lancet Nov 5;366(9497): Exclusion patients ayant déjàbénéficiéd une ATC ou àhaut risque hémorragique Comparaison : 75 mg clopidogrel+ 160 mg aspirine vs aspirine seule Thrombolyse non nécessaire pour être inclus ( étude CLARITY) Critère primaire : l ensemble des évènements CV majeurs: (décès, récidive d IDM, AVC) survenant avant la sortie de l hôpital (durée moyenne de suivi : 16 jours).

11 Lancet Nov 5;366(9497):

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17 Circulation 2010:122:

18 p=0.07 p=0.07 p=0.03 P=0.02

19 Therapeutic approaches in arterial thrombosis R. PHILLIPS et al. Journal of Thrombosis and Haemostasis, 2005:

20 P2Y12 inhibitors adjunctive to primary PCI therapy in STEMI: Fighting against the activated platelets Dimitrios Alexopoulos et al. International Journal of Cardiology 163 (2013)

21 Angiolillo DJ, Fernandez-Ortiz A, Bernardo E, et al. Variability in individual responsiveness to clopidogrel: clinical implications, management, and future perspectives. J Am Coll Cardiol 2007;49:

22 Effects of P2Y12 Receptor Inhibition in Patients With ST-Segment Elevation Myocardial Infarction Dimitrios Alexopoulos, et al. Am J Cardiol 2014, March 20, sous presse

23 Journal of the American College of Cardiology Vol. 56, No. 19, 2010 New P2Y12 Inhibitors Versus Clopidogrel in Percutaneous Coronary Intervention A Meta-Analysis Anne Bellemain-Appaix, et al. Sous groupe des STEMI

24 Prise en charge du SCA en amont de la salle de KT: aspirine seule ou dose de charge d un inhibiteur de la P2Y12? SCA ST+ = DAP

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26 Prise en charge du SCA en amont de la salle de KT: aspirine seule ou dose de charge d un inhibiteur de la P2Y12? SCA ST+ = DAP en amont de la salle de KT?

27 Patients undergoing primary PCI should receive a combination of DAPT with aspirin and an adenosine diphosphate (ADP) receptor blocker, as early as possible before angiography No trials to date have evaluated the commencement of DAPT prior to hospital admission, rather than in hospital, nor its use before, rather than during, angiography in the setting of STEMI, but this is common practice in Europe and is consistent with the pharmacokinetic data for oral antithrombotic agents, suggesting that the earliest administration would be preferable to achieve early efficacy.

28 Composition of Coronary Thrombus in Acute Myocardial Infarction Johanne Silvain et al. Journal of the American College of Cardiology Vol. 57, No. 12, 2011

29 Thrombus «frais» moins de 3h cristaux de cholestérol plaquettes

30 Thrombus de plus de 3 heures Riche en eyrthrocytes (b), globules blancs (a), fibrine (c) et quelques plaquettes agréguées (d)

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32 Circulation cardiovascular intervention 2012;5:

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36 Prise en charge du SCA en amont de la salle de KT: aspirine seule ou dose de charge d un inhibiteur de la P2Y12? SCA ST+ = DAP en amont de la salle de KT pour l instant

37 Ambulance or in-catheterization laboratory administration of ticagrelor for primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: Rationale and design of the randomized, double-blind Administration of Ticagrelor in the cath Lab or in the Ambulance for New ST elevation myocardial Infarction to open the Coronaryartery (ATLANTIC) study Gilles Montalescot, et al. Am Heart J 2013;165:515-22

38 Prise en charge du SCA en amont de la salle de KT: aspirine seule ou dose de charge d un inhibiteur de la P2Y12? SCA ST-

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40 Benefit of a 600-mg Loading Dose of Clopidogrel on Platelet Reactivity and Clinical Outcomes in Patients With Non ST-Segment Elevation Acute Coronary Syndrome Undergoing Coronary Stenting Thomas Cuisset et al. J Am Coll Cardiol. 2006; 48(7):

41 J Am Coll Cardiol. 2006; 48(7):

42 Association of Clopidogrel Pretreatment With Mortality, Cardiovascular Events, And Major Bleeding Among Patients Undergoing Percutaneous Coronary Intervention A Systematic Review and Meta-analysis Anne Bellemain-Appaix, et al JAMA. 2012;308(23):

43 Angiographic and platelet reactivity outcomes with prasugrel 60 mg pretreatment and clopidogrel 600 mg pretreatment in primary percutaneous coronary intervention Yiding Li et al. J Thromb Thrombolysis (2012) 34:

44 Journal of the American College of Cardiology Vol. 56, No. 19, 2010 New P2Y12 Inhibitors Versus Clopidogrel in Percutaneous Coronary Intervention A Meta-Analysis Anne Bellemain-Appaix, et al.

45 Journal of the American College of Cardiology Vol. 56, No. 19, 2010

46 Prise en charge du SCA en amont de la salle de KT: aspirine seule ou dose de charge d un inhibiteur de la P2Y12? SCA ST- = plutôt nouveaux inhibiteurs P2Y12 mais quand?...

47 Efficacy of High-Dose Clopidogrel Treatment (600 mg) Less Than Two Hours Before Percutaneous Coronary Intervention in Patients With Non ST-Segment Elevation Acute Coronary Syndromes Dmitriy N. Feldman et al. Am J Cardiol. 2010;105(3):

48 4033 patients SCA ST-, tropo + Prasugrel en dose de charge versus après coronarographie Critères principal: décès d origine cv, idm, avc, revascularisation urgente, usage d AGP IIb/IIIa)

49 Total population

50 Total population

51 PCI cohort

52 PCI cohort

53 Prise en charge du SCA en amont de la salle de KT: aspirine seule ou dose de charge d un inhibiteur de la P2Y12? SCA ST- = plutôt nouveaux inhibiteurs P2Y12 en salle de KT

54 Conclusion Pas de place à l aspirine seule SCA ST+ inhibiteurs des P2Y12: en amont de la salle de KT Place du prasugrel et du ticagrelor SCA ST- inhibiteurs des P2Y12: en salle de KT Place du prasugrel et du ticagrelor SCA ST- à haut risque?

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