TERAPIAANTITROMBOTICANELLASCAINPAZIENTICONFACRONICA

Dr.ssaPatriziaNoussanOspedaleSanGiovanniBosco

Torino

CardioAlessandria12-13giugno2015

FApermanenteeSCAunaassociazionepericolosa…..

•  PrevalenzadiFA1-2%•  L’80%deipazien;inFAhaindicazioneaOAC•  Il30%deipazien;inFAhaunaconcomitantepatologiavascolareenel20%andràincontroaPTCAconimpiantodistent

InEuropa1-2milionidipazienKinOACpotrebberoavereindicazioneaunaPTCAconstenKng

ReccomendaKonforanKthromboKctherapyinACS-NSTEeSTEMIpaKentsundergoingPCI

Primaryendpoint:firstoccurrenceofstroke,non-CNSsystemicembolus,AMIovasculardeath

(JAmCollCardiol2008;51:818–25)

Kaplan-MeierSurvivalCurvesinRelaKontoAnKcoagulaKonUseatDischarge

RiskofBleedingWithSingle,Dual,orTripleTherapyWithWarfarin,Aspirin,andClopidogrelinPaKentsWithAtrialFibrillaKon

Arch Intern Med. 2010;170(16):1433-1441. !

TRIPLETHERAPY(TT)ASA+P2Y12I+OAC(VKA/NOACS)

4-16%rischiodisanguinamen;

BleedingcomplicaKons ThromboKccomplicaKonsStroke–stentthrombosis

DUALTHERAPYOAC+SINGLEANTIPLATELET

50%isanguinamenK

2010

StudyDesign1:1Randomisa5on:Doubletherapygroup:OAC+75mgClopidogrelqd1monthminimumaSerBMS1yearaSerDES

TripletherapygroupOAC+75mgClopidogrelqd+80mgAspirinqd1monthminimumaSerBMS1yearaSerDES

Followup:1yearPrimaryEndpoint:Theoccurenceofallbleedingevents(TIMIcriteria)SecondaryEndpoints:- CombinaKonofstroke,death,myocardialinfarcKon,stentthrombosisandtargetvesselrevascularisaKon-Allindividualcomponentsofprimaryandsecondaryendpoints

TheWOESTTrial:FirstrandomisedtrialcomparingtworegimenswithandwithoutaspirininpaKentsonoralanKcoagulanttherapy

undergoingcoronarystenKng

|

PrimaryEndpoint:TotalnumberofTIMIbleedingevents

Days

Cumula;

veincide

nceofbleed

ing

0 30 60 90 120 180 270 365

0%

10%

20%

30%

40%

50%

284 210 194 186 181 173 159 140natrisk:279 253 244 241 241 236 226 208

TripletherapygroupDoubletherapygroup 44.9%

19.5%

p<0.001HR=0.3695%CI[0.26-0.50]

PrimaryEndpoint:BleedingeventsTIMIclassifica;on

05

101520253035404550

TIMIMinimal

TIMI Minor TIMI Major Any TIMIbleeding

Doubletherapygroup

Tripletherapygroup

6.5

16.7

11.2

27.2

3.35.8

19.5

44.9%

p<0.001

p<0.001

p<0.001

p=0.159

WOEST

|

Conclusions1.   FirstrandomizedtrialtoaddresstheopKmalanKplatelettherapyinpaKentsonOAC

undergoingcoronarystenKng

2.   Inthisstudywhichwasspecificallydesignedtodetectbleedingevents,thebleedingratewashigherthanexpected

3.   Primaryendpointwasmet:OACplusclopidogrelcauseslessbleedingthantripleanKthromboKctherapy,butnowshowninarandomizedway

4.   Secondaryendpointwasmet:withdoubletherapythereisnoexcessofthromboKc/thromboembolicevents:stroke,stentthrombosis,targetvesselrevascularisaKon,myocardialinfarcKonordeath

5.   Lessall-causemortalitywithdoubletherapy

LimiK:Numerositàdelcampione(576pts)-69%deipazienKerainOACperFA–accesso

femoralenel74%-PCIelejvanel70-75%-usononrouKnariodiPPI-TTper12mesi

JACCVol.62,2013;62:981–989

InreallifeAFpaKentswithindicaKonsformulKpleanKthromboKcdrugsakerMI/PCI,OACandclopidogrelwasequalorbemeronbothbenefitandsafeyoutcomes

comparedtotripletherapy

STEMIpaKents

ACS-NSTEpaKents

Ø PrincipalsaspectsoftheESCguidelinesareconsideredintherespondingcentresØ UncertaintyintheissueofopKmalcomposiKonandduraKonofmulKpleanKthromboKctreatmentandtheopKmalregimen(s)ofNOACSintreatmentstrategies

2014

ToevaluatewethershorteningtheduraKonofclopidogreltherapyfrom6monthsto6weeksakerDESimplantaKonwasassociatedwithasuperiornetclinicaloutcomeinpaKentsreceivingconcomitantaspirinandOAC

ThestudywilltestthehypotesisthatDAPTcomparedwithTTwithnonvalvularAFatlowtomoderateriskofstrokeCHADS2<2akerPCISreducestheriskofbleedingandisnotinferiortoTTforprevenKngthromboemboliccomplicaKons

PrimaryEndpoint:acompositeofDeath,MI,defST,strokeorTIMImajorbleedingat9months

NOACs•  IlruolodeiNOACsneipazien;conFAeACSnonè

statovalutatodireeamentemaderivasopraeueodaanalisipost-hocodaRCTssull’u;lizzodeiNOACsinassociazioneallaterapiaan;aggreganteneipazien;ACS-PCI

•  Quandosiu;lizzaunNOACinassociazioneaclopidogrelobassadosediASA,ladosediNOACdau;lizzareèlapiùbassatestataneglistudidiprevenzionedellostrokenellaFA

•  Unarecentemetanalisinonhaevidenziatodifferenzenell’incidenzadiIMAtraNOACseWarfarin

•  NOACstrialincorso:PIONEERAF-PCIRE-DUALPCI

Conclusions:RatesofthromboKcandbleedingeventsweresimilarinpaKentswithTTandpaKentswithTicagrelorandwarfarin

ConsensusrecommendaKon•  Nei pazien; con FA non valvolare u;lizzare gli score di rischio

CHA2DS2-VASC eHas-BLED eGRACERisk per la stra;ficazione delrischioACS

•  Se OAC è VKA à TTR>70% con INR 2-2.5 se in associazione aclopidogrele/oASA(75-100mg)(IIa,C)

•  SE OAC è NOAC , deve essere u;lizzata la posologia più bassadisponibile ma risultata efficace nella prevenzione dello strokeàDabigatran 110 b.i.d Rivaroxaban 15mg o.d. Apixaban 2.5mg b.i.d.(IIb,C)

•  Neipazien;conFAnonvalvolareecoronaropa;astabile>12mesimantenere VKA o NOAC (IIa, B). In casi seleziona;(PTCA di Tc, IVAprossimale , biforcazioni, IMA ricorren; ) si può considerare unprolungamentodelladupliceterapia(IIb,B)

•  Accessoradiale,“newgenera;on“DESvsBMS•  NOPrasugreleTicagrelornellaTT(III,C)