Gerinnungshemmung nach ACS und/oder Rekanalisation

Transkript

1 25. Grazer Fortbildungstage der Ärztekammer fu r Steiermark Pharmakotherapie 2014: Was ist gesichert, was ist obsolet? (Sie bestimmen mit!) Gerinnungshemmung nach ACS und/oder Rekanalisation Graz, 11. Oktober 2014, 09:40-10:00 Hannes Alber REHA ZENTRUM MÜNSTER Klinikum für Rehabilitation in Tirol UNIV.-KLINIK f. INNERE MED. III (KARDIO-/ANGIOLOGIE) Medizinische Universität Innsbruck

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3 Thrombus Aspiration

4 Antithrombotische Therapie nach ACS

5 Frage 1 68 Frau, NSTEMI vor 9 Tagen, Stent in LAD; CRF: Hypertonie, Nikotin, Hypercholesterinämie Wie lange T-ASS plus Prasugrel/Ticagrelor/Clopidogrel? 1. 6 Monate Monate Monate Monate

6 DAPT in Guidelines NSTE-ACS 2011 and STEMI 2012 P2Y 12 inh.: as soon as possible, for up to 12 mo (LOE A) Ticagrelor Prasugrel Clopidogrel An ADP-receptor blocker is recommended in addition to aspirin for up to 12 months (IA after PCI, IIaC after no stent). Options are: (LOE A) Prasugrel in clopidogrel-naive pts., if no history of prior stroke/tia, age <75 years (LOE B) Ticagrelor (LOE B) Clopidogrel, preferably when prasugrel or ticagrelor are either not available or contraindicated (LOE C) Class I Class IIa Class IIb Class III (LD 180mg, MD 2x90mg/d) for moderate-to-high risk pts. regardless of initial treatment including those pretreated with clopidogrel (LOE B) (LD 60mg, MD 10mg/d) for P2Y 12 inhibitor-naive pts. (espec. DM) with known coronary anatomy proceeding to PCI unless high bleeding risk or other contraindication (LOE B) (LD 300mg, MD 75mg/d) for patients who cannot receive Ticagrelor or Prasugrel (LOE A) LD 600mg in case of invasive strategy (LOE A) MD 150mg for 7 days after PCI + no bleeding risk (LOE B)

7 DAPT in ACS CURE n = ACS/NSTEMI pts. on ASA (75-325mg); FU: 3-12mo (median 9mo) Clopidogrel (LD 300mg, MD 75mg) vs. Placebo 1 EP: CV death, MI, stroke Yusuf S et al. NEJM 2001.

8 Bleeding with DAPT in ACS CURE Yusuf S et al. NEJM 2001.

9 New P2Y 12 receptor antagonists in ACS PLATO (Ticagrelor) and TRITON (Prasugrel) PLATO n=18,624 NSTE-ACS+STEMI (if ppci) testing Ticagrelor (180mg LD, 2x90mg MD) TRITON-TIMI 38 n=13,609 ACS (undergoing PCI) testing Prasugrel (60mg LD, 1x10mg MD) Comparator in both trials: Clopidogrel (300mg/75mg) Wallentin L et al., NEJM 2009; 361: Wiviott ED et al. NEJM 2007; 357:

10 ESC GL on Myoc. Revasc Antiplatelets in STEMI undergoing ppci ASA is recommended for all pts. w/o contraindications at an initial oral LD of mg (or mg i.v.) and at a MD of mg daily long-term regardless of treatment strategy. (LOE: A) A P 2 Y 12 inhibitor is recommended in addition to ASA and maintained over 12 months unless there are contraindications such as excessive risk of bleeding. (LOE: A) Options are: * Prasugrel (60mg LD, 10mg OD) if no contraindication (LOE: B) * Ticagrelor (180mg LD, 90mg BID) if no contraindication (LOE: B) * Clopidogrel (600mg LD, 75mg OD) only when prasugrel or ticagrelor are not available or are contraindicated (LOE: B) It is recommended to give P 2 Y 12 inhibitors at the time of FMC (LOE: B) GPI should be considered for bail-out or evidence of no-reflow or a thrombotic complication (LOE: C). Upstream use of a GPI (vs. in-lab use) may be considered in high-risk patients undergoing transfer for primary PCI (LOE: B). Class I Class IIa Class IIb Class III Windecker S et al., EHJ 2014; doi: /eurheartj/ehu278

11 ESC GL on Myoc. Revasc Oral antiplatelets in NSTE-ACS undergoing PCI ASA is recommended for all pts. w/o contraindications at an initial oral LD of mg (or mg i.v.) and at a MD of mg daily long-term regardless of treatment strategy. (LOE: A) A P 2 Y 12 inhibitor is recommended in addition to ASA and maintained over 12 months unless there are contraindications such as excessive risk of bleeding. (LOE: A) Options are: Prasugrel (60mg LD, 10mg OD) in patients in whom coronary anatomy is known and who are proceeding to PCI if no contraindication.(loe: B) Ticagrelor (180mg LD, 90mg BID) for patients at moderate-to-high risk of ischaemic events, regardless of initial treatment strategy including those pretreated with clopidogrel if no contraindication. (LOE: B) Clopidogrel (600mg LD, 75mg OD), only when prasugrel or ticagrelor are not available or are contraindicated. (LOE: B) Pre-treatment with prasugrel in pts. In whom coronary anatomy is not known, is not recommended. (LOE: B) Class I Class IIa Class IIb Class III Windecker S et al., EHJ 2014; doi: /eurheartj/ehu278

12 Antwort 1 68 Frau, NSTEMI vor 9 Tagen, Stent in LAD; CRF: Hypertonie, Nikotin, Hypercholesterinämie Wie lange T-ASS plus Prasugrel/Ticagrelor/Clopidogrel? 1. 6 Monate Monate Monate Monate

13 Antithrombotische Therapie nach Stents

14 Antithrombotische Therapie nach Stents bei stabiler KHK

15 Frage 2 68 Frau, stabile AP, positive Ergometrie, Neu-Generations-DES (z.bsp. Integrity Resolute, Xience, Orsiro,...) in LAD; CRF: Hypertonie, Nikotin, Hypercholesterinämie Wie lange T-ASS plus Clopidogrel? 1. 1 Monat 2. 6 Monate Monate Monate

16 DAPT ACCP Guidelines For patients undergoing PCI with a DES, we recommend aspirin (75-100mg/d) plus clopidogrel (75mg/d for at least 12 months) [Grade 1A for 3-4 months, Grade 1B for 4-12 months]. Beyond 1 year, we suggest continued treatment with aspirin plus clopidogrel indefinitely if no bleeding or other tolerability issues (Grade 2C) 39 Seiten: ACCP: Chest 2008; 133: 776S-814S.

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19 PRODIGY (1:1:1:1 to EES:ZES:PES:BMS)

20 Prolonged DAPT PRODIGY n = 2013 pts. randomized 1:1:1:1 to EES:ZES:PES:BMS At 30 days randomized to 6 or 26 months DAPT 24-Apr-2012; Valgimigly M et al. Circulation 2012; 125:

21 Prolonged DAPT PRODIGY 1 EP 1 EP: any death, MI, cerebrovascular accident 24-Apr-2012; Valgimigly M et al. Circulation 2012; 125:

22 Prolonged DAPT PRODIGY Stent thrombosis (def./prob.) 24-Apr-2012; Valgimigly M et al. Circulation 2012; 125:

23 Prolonged DAPT PRODIGY Bleedings BARC bleedings type 5, 3 or 2 24-Apr-2012; Valgimigly M et al. Circulation 2012; 125:

24 EXCELLENT (ZES) OPTIMIZE (EES)

25 Antwort 2 68 Frau, stabile AP, positive Ergometrie, Neu-Generations-DES (z.bsp. Integrity Resolute, Xience, Orsiro,...) in LAD; CRF: Hypertonie, Nikotin, Hypercholesterinämie Wie lange T-ASS plus Clopidogrel? 1. 1 Monat 2. 6 Monate Monate Monate

26 Frage 3 68 Frau, stabile AP, pos. Ergometrie, Zotarolimus-eluting Stent in LAD; VHF seit Jahren unter Xarelto 20mg/Pradaxa 2x150mg/Eliquis 2x5mg CRF: Hypertonie, Nikotin, Hypercholesterinämie Welche antithrombotische Strategie? (CHADS-VASc: 4, HAS-BLED: 1) 1. Xarelto 20mg/Pradaxa 2x150mg/Eliquis 2x5mg + ASS + Clopidogrel für 12 Monate, dann Xarelto 20mg/Pradaxa 2x150mg/Eliquis 2x5mg 2. ASS 100mg + Clopidogrel 75mg für 12 Monate, dann wieder Xarelto 20mg/Pradaxa 2x150mg/Eliquis 2x5mg 3. Xarelto 15mg/Pradaxa 2x110mg/Eliquis 2x2,5mg + Clopidogrel + ASS für 6 Monate, dann Xarelto 15mg/Pradaxa 2x110mg/Eliquis 2x2,5mg + Clopidogrel von Monat 6-12, dann Xarelto 20mg/Pradaxa 2x150mg/Eliquis 2x5mg 4. Xarelto 20mg/Pradaxa 2x150mg/Eliquis 2x5mg + ASS + Clopidogrel für 4 Wochen, dann Xarelto 20mg/Pradaxa 2x150mg/Eliquis 2x5mg + ASS

27 TOAT in AFib and CAD

28 AFib and CAD Swiss experience n=6041 consecutive pts. undergoing DES implantation n=323 (5.3%) with documented AFib: CHADS 2 -Score 2 in n=203 (62%) 40.5% were on VKA at the end of FU medication at discharge: n=315 (98%): ASA n=321 (99%): Clopidogrel n=62 (19.2%): VKA recommended after 3mo Pilgrim T et al.; Eurointervention 2013; 8:

29 Triple Therapy in AF + MI/PCI bleedings and ischaemic events Lamberts M et al., Circulation 2012; 126:

30 AF and PCI Consensus paper Lip GYP et al., EHJ 2014; doi: /eurheartj/ehu298; published online 25-Aug-2014

31 AF + PCI/MI - General Recommendations Risk stratification (CHA 2 DS 2 -VASc, HAS-BLED) regularly repeated (i.e. 1x/y) (LOE:C) VKA TTR > 70% recommended (LOE:A) VKA + Cl a/o ASA: INR target (LOE:C) NOAC + Cl a/o ASA: use lower tested NOAC dose (i.e. Dab. 2x110mg, Riv. 1x15mg, Apix. 2x2.5mg) (LOE:C) >1 yr. after acute ischaemic event/repeat revasc.: OAC alone (LOE:C) >1 yr. after acute ischaemic event/repeat revasc.: DOAT (i.e. OAC + Cl {ASA}) only in selected pts. (i.e. LM, prox. LAD, prox. Bifurc., rec. MI, etc) (LOE:C) Prasugrel and Ticagrelor not part of triple therapy (LOE:C) Prasugrel or Ticagrelor combined with OAC only in certain circumstances (def. Stent thrombosis under Cl+ASA+OAC) (LOE:C) PPI in pts. on OAC + antiplatelet (LOE:C) Class I Class IIa Class IIb Class III modified from Lip GYP et al., EHJ 2014; doi: /eurheartj/ehu298; published online 25-Aug-2014

32 AF and PCI/MI Consensus Document 2014 Lip GYP et al., EHJ 2014; doi: /eurheartj/ehu298; published online 25-Aug-2014

33 Lip GYP et al., EHJ 2014; doi: /eurheartj/ehu298; published online 25-Aug-2014 AF and PCI/MI Choice of antithrombotic therapy Choice of antithrombotic therapy, incl. combination strategies of OAC (O), ASS (A) and/or clopidogrel (C). For step 4, background colour and gradients reflect intensity of antithrombotic therapy (i.e. dark = high intensity; light = low intensity). Solid boxes = recommended drugs. Dashed boxes = optional drugs depending on clinical judgement New generation DES is generally preferable over BMS, particularly in patients with low bleeding risk (HAS-BLED 0-2). When VKA are used as part of triple therapy: INR target TTR >70% * DOAT (OAC plus clopidogrel may be considered in selected pts.) ** ASA as an alternative to clopidogrel may be considered in DOAT (OAC +SAPT) *** DOAT (OAC+SAPT (ASA or clopidogrel)) may be considered in pts. with very high risk of coronary events

34 Non-valv. AF and PCI in ACS Consensus document Lip GYP et al., EHJ 2014; doi: /eurheartj/ehu298; published online 25-Aug-2014 CHA s DS 2 -VASC = 1 CHA s DS 2 -VASC 2 HAS-BLED: 0-2 HAS-BLED 3 HAS-BLED: 0-2 HAS-BLED 3 4we 6mo 12mo

35 Non-valv. AF and PCI in SCAD if PCI Consensus document Lip GYP et al., EHJ 2014; doi: /eurheartj/ehu298; published online 25-Aug-2014 CHA s DS 2 -VASC = 1 CHA s DS 2 -VASC 2 HAS-BLED: 0-2 HAS-BLED 3 HAS-BLED: 0-2 HAS-BLED 3 4we 6mo 12mo

36 Non-valv. AF and PCI in SCAD if PCI Consensus document Lip GYP et al., EHJ 2014; doi: /eurheartj/ehu298; published online 25-Aug-2014 CHA s DS 2 -VASC = 1 CHA s DS 2 -VASC 2 HAS-BLED: 0-2 HAS-BLED 3 HAS-BLED: 0-2 HAS-BLED 3 4we 6mo 12mo

37 Antwort 3 68 Frau, stabile AP, pos. Ergometrie, Zotarolimus-eluting Stent in LAD; VHF seit Jahren unter Xarelto 20mg/Pradaxa 2x150mg/Eliquis 2x5mg CRF: Hypertonie, Nikotin, Hypercholesterinämie Welche antithrombotische Strategie? (CHADS-VASc: 4, HAS-BLED: 1) 1. Xarelto 20mg/Pradaxa 2x150mg/Eliquis 2x5mg + ASS + Clopidogrel für 12 Monate, dann Xarelto 20mg/Pradaxa 2x150mg/Eliquis 2x5mg 2. ASS 100mg + Clopidogrel 75mg für 12 Monate, dann wieder Xarelto 20mg/Pradaxa 2x150mg/Eliquis 2x5mg 3. Xarelto 15mg/Pradaxa 2x110mg/Eliquis 2x2,5mg + Clopidogrel + ASS für 6 Monate, dann Xarelto 15mg/Pradaxa 2x110mg/Eliquis 2x2,5mg + Clopidogrel von Monat 6-12, dann Xarelto 20mg/Pradaxa 2x150mg/Eliquis 2x5mg 4. Xarelto 20mg/Pradaxa 2x150mg/Eliquis 2x5mg + ASS + Clopidogrel für 4 Wochen, dann Xarelto 20mg/Pradaxa 2x150mg/Eliquis 2x5mg + ASS

38 Antithrombotische Therapie nach ACS Antithrombotische Therapie nach Stent bei stabiler KHK Antithrombotische Kombinationstherapie bei PCI in Pat. mit Indikation für eine OAK

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