Dauer der doppelten Plättchenhemmung nach AMI / Stent Kardio-Lunch 04.06.2014 Christoph Kaiser Universitätsspital Basel Christoph.kaiser@usb.ch
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;1084-89
DAPT after Stenting 1 653 mostly stable patients with PCI & stent Primary endpoint: death, TLR, stent thrombosis, MI < 30 days Leon M; N Engl J Med 1998;1665-71
DAPT after Stenting 1 653 mostly stable patients with PCI & stent Primary endpoint: death, TLR, stent thrombosis, MI < 30 days Leon M; N Engl J Med 1998;1665-71
DAPT and ACS CURE-Trial: 12 562 patients with NSTEMI-ACS; ASS & Clopidogrel vs ASS & Placebo over 12 months 11.4% 9.3% 20% RRR P < 0.001 CURE-Investigators, N Engl J Med. 2001;345:494-502
Long-Term DAPT after Stenting CREDO-Trial: 2 216 patients with elective stenting: ASS and Clopidogrel vs ASS and Placebo over 12 months Steinhubl SR et al. JAMA 2002;288:2411-21
DAPT in high-risk patients? CHARISMA: 15 603 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;354:1706-17
DAPT in high-risk patients? CHARISMA: 15 603 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;354:1706-17
DAPT in high-risk patients? CHARISMA: 15 603 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;354:1706-17
DAPT in high-risk patients? CHARISMA: 15 603 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;354:1706-17
2006-2014 DAPT for 12 Months After ACS and DES
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
Time Course of bleeding under DAPT CHARISMA: 15 603 with cv-disease or multiple risk factors: Clopidogrel & ASS versus ASS alone for 28 months Bleeding 0-12 months Bleeding 12-30 months Berger P et al. Circulation 2010;121:2575-83
The threat of late/very late stent thrombosis Mauri L, et al. Am Heart J 2010;160:1035-41
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.
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
The effect of 2nd generation DES and Time
Stent thrombosis with 2nd generation DES Single center: n=3 844 Metaanalysis, n= 12 866 Dores H, et al. J Invasive Cardio. 2013;25:330-6 Philip, F, et al. Circ Cardiovasc Interv 2014;7:49-61
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;125:2015-26
DAPT-duration after elective stenting 2014 ESC-Guidelines on myocardial revascularization
AHA 2014 - The opposite: Extension of DAPT-duration after stenting
Extension of DAPT-duration after stenting Mauri L, et al. N Engl J Med 2014;371:2155-66
Extension of DAPT-duration after stenting Mauri L, et al. N Engl J Med 2014;371:2155-66
Extension of DAPT-duration after stenting 75% elective Mauri L, et al. N Engl J Med 2014;371:2155-66
Extension of DAPT-duration after stenting Mauri L, et al. N Engl J Med 2014;371:2155-66
Extension of DAPT-duration after stenting Mauri L, et al. N Engl J Med 2014;371:2155-66
Extension of DAPT-duration after stenting Mauri L, et al. N Engl J Med 2014;371:2155-66
Extension of DAPT-duration after stenting
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%)
ESC 2015 Extension of DAPT-duration after MI due to introduction of 2nd generation Thioenopyridines
2nd generation Thioenopyridines n= 13 608 n= 18 624 Wiviott S et al. N Engl J Med 2007;357:2001-15 Wallentin L et al. N Engl J Med 2009:361:1-13
Extension of DAPT-duration after MI REACH-Registry: n=64 977 > 45 years old: 4 year outcomes Bhatt DL, et al. JAMA 2010;304:1350-7
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;49:1982-88
Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372:1791-800
Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372:1791-800
Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372:1791-800
Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372:1791-800
Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372:1791-800
Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372:1791-800 Prof. D. Trenk, Herzzentrum Bad Krozingen
Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372:1791-800
Extension of DAPT-duration after MI Bonaca MP, et al. N Engl J Med 2015;372:1791-800 Prof. D. Trenk, Herzzentrum Bad Krozingen
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
Near future I: Guideline Update
Near future II: Rather Mono than Bi
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