The Contemporary Anti-thrombotic Therapy in ACS ACSIS Shlomi Matetzky On Behalf of the ACSIS 2013 Investigators

Transcription

1 The Contemporary Anti-thrombotic Therapy in ACS ACSIS 213 Shlomi Matetzky On Behalf of the ACSIS 213 Investigators

2 2 What's New in ACSIS 213?

3

4

5 Aim : To explore the contemporary anti-thrombotic therapy in ACS in Israel

6 Chronic Anti-Platelet Therapy (Prior to the Index ACS) %Pts 6 5 ASA 49.8% %Pts % P2Y12 Blockers 15.2% %.6% 6 Plavix Prasugrel Ticagrelar Any P2Y12 Blockers

7 Anti-Platelet Therapy from FMC to Cardiology (Pre-hospital, MICCU, ED) Emergency Room

8 G Montalescot, L Bolognese, D Dudek, P Goldstein, C Hamm, JF Tanguay, JM ten Berg, DL Miller, TM Costigan, J Goedicke, J Silvain, P Angioli, J Legutko, M Niethammer, Z Motovska, JA Jakubowski, G Cayla, LO Visconti, E Vicaut, P Widimsky for the ACCOAST investigators COI DISCLOSURE FOR DR. MONTALESCOT are

9 All ACS STEMI/PPCI %Pts ASA 77% %Pts ASA 91% %Pts 3 2 P 2 Y 12 Blockers (38%) 22.5% Plavix Prasugrel Ticagrelar 4 P 2 Y 12 Blockers % Clopidogrel % 2 23% 1 2.3% 9

10 The Use of P2Y12 Blockers in Patients Undergoing PPCI STEMI/PPCI Clopidogrel 149 (26.4%) Prasugrel 344 (6.9%) Ticagrelor 72 (12.7%) Before Procedure 31 (88%) Before Procedure 251 (73%) Before Procedure 6 (83%)

11 The Use of P2Y12 Blockers in Patients Undergoing PPCI STEMI/PPCI Clopidogrel 149 (26.4%) Prasugrel 344 (6.9%) Ticagrelor 72 (12.7%) Before Procedure 31 (88%) Before Procedure 251 (73%) Before Procedure 6 (83%)

12 The Use of GP IIb/IIIa Antagonists in PPCI STEMI/PPCI N=568 GP IIb/IIIa N=238 (42%) Before 16 (7%) During/After 222 (93%)

13 The Use of GP IIb/IIIa Antagonists in PPCI STEMI/PPCI N= : 256\515(49.7%) GP IIb/IIIa N=238 (42%) Before 16 (7%) During/After 222 (93%)

14 Anti-Coagulant Therapy in STEMI/PPCI 1.5% 16% 2.5% Hepa Heparin Birali Angiomax 8% Other LWH LMWH 14

15 The Use of GP IIb/IIIa Antagonists in (non-ppci) PCI %Pts % % 7.9% UA NSTEMI STEMI 15

16 Anti-Coagulant in NSTEMI Patients Undergoing PCI %Pts 49.7% 45.9% 4.4% 16

17 Discharge ASA %Pts % 88.2% 96.6% 83.3% 97.9% All ACS NSTEMI No PCI NSTEMI PCI STEMI No PCI STEMI/PCI

18 Discharge ASA %Pts % 88.2% 96.6% 83.3% 97.9% All ACS NSTEMI No PCI NSTEMI PCI STEMI No PCI STEMI/PCI

19 Discharge ASA %Pts % 88.2% 96.6% 83.3% 97.9% All ACS NSTEMI No PCI NSTEMI PCI STEMI No PCI STEMI/PCI

20 Discharge P 2 Y 12 Receptor Blockers: All ACS %Pts % % 27.4% 15.6% Clopidogrel Prasugrel Ticagrelor Any P2Y12 Blockers 2

21 Anti-Platelet Treatment at Discharge: ACSIS % Aspirin P2Y12 Blockers

22 Discharge P 2 Y 12 Receptor Blockers: All ACS %Pts % % 27.4% 15.6% Clopidogrel Prasugrel Ticagrelor Any P2Y12 Blockers 22

23 Discharge P 2 Y 12 Receptor Blockers : AMI Patients Undergoing PCI %Pts % % 41.6% 21.6% Clopidogrel Prasugrel Ticagrelor Any P2Y12 Blockers 23

24 24 Discharge P 2 Y 12 Receptor Blockers

25 In-hospital Major Bleeding %Pts 1 NSTEMI\PCI %Pts 1 STEMI\PPCI.9%.5.67%.5.29% % Clopidogrel Prasugrel Ticagrelor % % Clopidogrel Prasugrel Ticagrelor

26 Switching between different agents

27 Switching P 2 Y 12 Blockers Throughout Hospital Course Clopidogrel N=153 Clopidogrel N=731 (69.4%) Prasgugrel N=88 (8.4%) Ticagrelar N=11 (9.6%) None N=133 (12.6%) 27

28 Switching P 2 Y 12 Blockers Throughout Hospital Course Clopidogrel N=153 Clopidogrel N=731 (69.4%) Prasgugrel N=88 (8.4%) Ticagrelar N=11 (9.6%) None N=133 (12.6%) 28

29 Switching P 2 Y 12 Blockers Throughout Hospital Course Prasugrel N=481 Prasgugrel N=44 (84%) Clopidogrel N=28 (5.8%) Ticagrelar N=18 (3.7%) None N=31 (6.5%) 29

30 Switching P 2 Y 12 Blockers Throughout Hospital Course Prasugrel N=481 Prasgugrel N=44 (84%) Clopidogrel N=28 (5.8%) Ticagrelar N=18 (3.7%) None N=31 (6.5%) 3

31 Switching P 2 Y 12 Blockers Throughout Hospital Course Ticagrelor N=241 Ticagrelor N=171 (7.7%) Clopidogrel N=28 (11.6%) Prasugrel N=11 (4.5%) None N=31 (12.6%) 31

32 Switching P 2 Y 12 Blockers Throughout Hospital Course Ticagrelor N=241 Ticagrelor N=171 (7.7%) Clopidogrel N=28 (11.6%) Prasugrel N=11 (4.5%) None N=31 (12.6%) 32

33 The Changes in P2Y12 Blockers Throughout Hospitalization % Consistent P2Y12 blocker therapy 15% Switching P2Y12 blocker therapy 11% Discontinuation P2Y12 blocker therapy

34 Switching P 2 Y 12 Blockers Throughout Hospital Course 1 3.5% 13.1% 14.1% % 15.7% % Clopidogrel Prasugrel 4 Ticagrelor None % 42.9% st P2Y12 Blocker Discharge P2Y12 Blocker

35 Switching P 2 Y 12 Blockers Throughout Hospital Course 1 3.5% 13.1% 14.1% % 15.7% % Clopidogrel Prasugrel 4 Ticagrelor None % 42.9% st P2Y12 Blocker Discharge P2Y12 Blocker

36 1 ACSIS Inter-Center Variation According to the Use of Clopidogrel vs. a New Anti-Platelate Agent in Pts with NSTEMI Undergoing PCI Clopidogrel New Anti-platelat

37 ACSIS Inter-Center Variation According to the Use of the New Anti-Platelate Agents in Pts with NSTEMI Undergoing PCI Ticagrelor Prasugrel

38 Conclusions: AS many as 5% of ACS represent ASA Failure and 15% P2Y12 antagonists Failure Of the STEMI Pts undergoing PPCI about 3\4 are being facilitated by one of the new anti-platelet agents Among NSTEMI including among those who underwent PCI, clopidogrel continues to be the most prevalent P2Y12 blocker The P2Y12 therapy is being switched in only 15% of ACS Pts There is significant nationwide variability in anti-platelet therapy policy

39 Discharge Oral Anti-Coagulant %Pts % 4 4.7% % Warfarin NOAC Any Oral Anti- Coagulant

40 21% The Effect of Oral Anti-Coagulant Use on Anti-Platelet Therapy: % Pts treated with Clopidogrel % 9% NSTEMI\PCI 19.4% 78% STEMI\PPCI No OAC OAC

41 In-hospital Definite\Probable Stent Thrombosis NSTEMI\PCI STEMI\PPCI %Pts 1.5 P=.4 P=.7 %Pts.6% % % Clopidogrel Prasugrel Ticagrelor % 2% 1.45% Clopidogrel Prasugrel Ticagrelor