CLASIFICACIÓN SCA

SINDROME CORONARIO AGUDO

ACTUALIZACIÓN 2014

GUÍAS AHA/ACC SCASEST 2014

NUEVAS EVIDENCIAS ANTIAGREGANTES

Dr. Iñaki Lekuona Sº Cardiología HGU Osakidetza

SCASEST vs SCACEST

European Heart Journal (2011) 32, 2999–3054

ESTRATEGIA INICIAL SCASEST

European Heart Journal (2011) 32, 2999–3054

PRESENTACIÓN CLÍNICA SCASEST

European Heart Journal (2011) 32, 2999–3054

ELECTROCARDIOGRAMA SCASEST

European Heart Journal (2011) 32, 2999–3054

BIOMARCADORES SCASEST

European Heart Journal (2011) 32, 2999–3054

PRUEBAS NO INVASIVAS SCASEST

European Heart Journal (2011) 32, 2999–3054

VALORACIÓN DEL RIESGO INDIVIDUAL

European Heart Journal (2011) 32, 2999–3054

http://www.outcomes-umassmed.org/grace/

MARCADORES DE RIESGO SCASEST

European Heart Journal (2011) 32, 2999–3054

CAUSAS DE ELEVACIÓN DE Tn EN SCASEST

European Heart Journal (2011) 32, 2999–3054

ANTIAGREGANTES PLAQUETARIOS EN SCASEST

European Heart Journal doi:10.1093/eurheartj/ehu160 2014

European Heart Journal Doi:10.1093/eurheartj/ehu160 2014

PLATO SCASEST

Objetivo Primario Todas las causas de muerte

European Heart Journal doi:10.1093/eurheartj/ehu160 2014

PLATO SCASEST

Tiempo hasta la hemorragia mayor Tiempo hasta hemorragia no dependiente CBAO

European Heart Journal doi:10.1093/eurheartj/ehu160 2014

PLATO SCASEST

SCASEST o non-STEMI

Indicadores primarias Cambios dinámicos ST, elevación troponinas Indicadores secundarias Diabetes, GRACE score > 140, FEVI <40% Crp <60 ml/min

Riesgo de hemorragia CRUSADE, ACUITY

Acceso radial

PRUEBAS INVASIVAS

European Heart Journal (2011) 32, 2999–3054

ESTRATIFICACIÓN DEL RIESGO TIMI AHA 2014

ESTRATIFICACIÓN SCASEST AHA 2014

10.1016/j.jacc.2014.09.017

BIOMARCADORES SCASEST AHA 2014

10.1016/j.jacc.2014.09.017

10.1016/j.jacc.2014.09.017

TRATAMIENTO SCASEST 2014

10.1016/j.jacc.2014.09.017

TRATAMIENTO SCASEST 2014

10.1016/j.jacc.2014.09.017

TRATAMIENTO SCASEST 2014: ANTIAGREGANTES

10.1016/j.jacc.2014.09.017

TRATAMIENTO SCASEST 2014

10.1016/j.jacc.2014.09.017

10.1016/j.jacc.2014.09.017

ESTRATEGIA EN FUNCIÓN DEL RIESGO

TRATAMIENTO ANTISQUÉMICO SCASEST

European Heart Journal (2011) 32, 2999–3054

TRATAMIENTO ANTIPLAQUETARIO SCASEST

European Heart Journal (2011) 32, 2999–3054

TRATAMIENTO ANTIPLAQUETARIO SCASEST

European Heart Journal (2011) 32, 2999–3054

TRATAMIENTO ANTICOAGULANTE SCASEST

European Heart Journal (2011) 32, 2999–3054

ESTRATEGIA INVASIVA SCASEST

European Heart Journal (2011) 32, 2999–3054

POBLACIONES y SITUACIONES ESPECIALES SCASEST

European Heart Journal (2011) 32, 2999–3054

ESTRATEGIA INVASIVA SCASEST

European Heart Journal (2011) 32, 2999–3054

TRATAMIENTO ANTICOAGULANTE EN SCASEST non-STEMI

European Heart Journal (2011) 32, 2999–3054

COI DISCLOSURE FOR DR. MONTALESCOT are availalble @ http://www.action-coeur.org

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

● Pre-treatment with aspirin and a P2Y12 antagonist has been a class I recommendation and common practice for the treatment of NSTE-ACS

● However, no trial has ever randomized patients presenting with NSTE-ACS, invasively managed, to pre-treatment with clopidogrel, prasugrel or ticagrelor vs. no pre-treatment.

ACCOAST design

Prasugrel 30 mg

Prasugrel 60 mg Prasugrel 30 mg

Prasugrel 10 mg or 5 mg (based on weight and age) for 30 days

PCI

1° Endpoint: CV Death, MI, Stroke, Urg Revasc, GP IIb/IIIa bailout, at 7 days

Placebo

Coronary Angiography

n~4100 (event driven)

Coronary Angiography

PCI

CABG

or

Medical

Management

(no prasugrel)

CABG

or

Medical

Management

(no more prasugrel)

Montalescot G et al. Am Heart J 2011;161:650-656

Randomize 1:1 Double-blind

NSTEMI + Troponin ≥ 1.5 times ULN local lab value Clopidogrel naive or on long term clopidogrel 75 mg

Days From First Dose

0 5 10 15 20 25 30

End

po

int

(%)

0

5

10

15

1996

2037

1788

1821

1775 1769

1802

1762

1797

1752

1791

CV Death, MI, Stroke, UR, GPIIb/IIIa Bailout

1621

1616

No. at Risk, Primary

Efficacy End Point:

No pre-treatment

Pre-treatment

Pre-treatment 10.8 10.0

Pre-treatment

Hazard Ratio, 0.997 (95% 0.83, 1.20) P=0.98 P=0.81

(95% 0.84, 1.25) Hazard Ratio, 1.02

No Pre-treatment 10.8

9.8 No Pre-treatment

1° Efficacy End Point @ 7 + 30 days (All Patients)

All TIMI (CABG or non-CABG) Major Bleeding (All Treated patients)

Days From First Dose

0 5 10 15 20 25 30

End

po

int

(%)

0

1

2

3

4

5

All TIMI Major Bleeding

Pre-treatment 2.9

Pre-treatment 2.6

No Pre-treatment 1.5

No Pre-treatment 1.4

1996 2037

1947 1972

1328 1339

1297 1310

1288 1299

1284 1297

1263 1280

No. at Risk, All TIMI Major Bleeding: No pre-treatment Pre-treatment

Hazard Ratio, 1.97 (95% 1.26, 3.08) P=0.002

Hazard Ratio, 1.90 (95% 1.19, 3.02) P=0.006

Conclusions

● In NSTE-ACS patients managed invasively within 48 hours of admission, pre-treatment with prasugrel does not reduce major ischemic events through 30 days but increases major bleeding complications.

● The results are consistent among patients undergoing PCI supporting treatment with prasugrel once the coronary anatomy has been defined.

● No subgroup appears to have a favorable risk/benefit ratio of pre-treatment.

● Reappraisal of routine pre-treatment strategies in NSTE-ACS is needed.

Administration of Ticagrelor in the cath Lab or in the Ambulance for New ST elevation myocardial Infarction to

open the Coronary artery

G. Montalescot, COI are available at www.action-coeur.org

G. Montalescot, A.W. van’t Hof, F. Lapostolle, J Silvain, J.F. Lassen, L. Bolognese, W.J. Cantor, A. Cequier, M. Chettibi, S.G. Goodman, C.J. Hammett, K. Huber, M. Janzon,

B. Merkely, R.F. Storey, U. Zeymer, O. Stibbe, P. Ecollan, W.M.J.M. Heutz, E. Swahn, J.P. Collet, F.F. Willems, C. Baradat, M. Licour, A. Tsatsaris, E. Vicaut, C.W. Hamm,

for the ATLANTIC investigators

In-hospital new oral P2Y12 antagonists Primary PCI of STEMI

Pre-specified clinical 2° endpoints

• Composite of death, MI, stent thrombosis, stroke or urgent revascularization at 30 days

• Definite stent thrombosis at 30 days

• Thrombotic bailout with GPIIb/IIIa inhibitors

Study population and design

Safety objectives

• Bleeding (excluding CABG related events)

– PLATO definition

– TIMI, STEEPLE, GUSTO, ISTH and BARC definitions

– Within first 48h and during 30 days of treatment

• Other safety events within 30 days of study treatment

Major adverse CV events up to 30 days

Definite stent thrombosis up to 10 days

Definite stent thrombosis up to 30 days

Clinical endpoints at 30 days

Values are % Odds ratio

(95% CI) p-value

Death (all-cause) 1.68

(0.94, 3.01) 0.08

MI 0.73

(0.28, 1.94) 0.53

Stroke 2.11

(0.39, 11.53) 0.39

TIA Not

estimable Urgent coronary revascularization

0.66 (0.21, 2.01) 0.46

Bail-out GP IIb/IIIa inhibitors 0.80

(0.59, 1.10) 0.17

Non-CABG-related bleeding events (PLATO definitions) - Safety population

Conclusion

La administración prehospitalaria de Ticagrelor previo a la ICP en pacientes con SCACEST es segura pero no mejora la reperfusión. Sin embargo reduce el riesgo de trombosis de stent psot ICP

PUBLICACIÓN DEL ATLANTIC

REGISTRO COMPARANDO CLOPIDOGREL CON PRASUGREL EN PRÁCTICA CLÍNICA EN USA