Company, TIMI Study Group, WebMD.
29
Dr. Montalescot reports research Grants to the Institution or Consulting/Lecture Fees from ADIR, Amgen, AstraZeneca, Bayer, Berlin Chimie AG, Boehringer Ingelheim, Bristol-Myers Squibb, Beth Israel Deaconess Medical, Brigham Women’s Hospital, Cardiovascular Research Foundation, Celladon, CME Resources, Daiichi- Sankyo, Eli-Lilly, Europa, Elsevier, Fédération Française de Cardiologie, Fondazione Anna Maria Sechi per il Cuore, Gilead, ICAN, Janssen, Lead-Up, Menarini, Medtronic, MSD, Pfizer, Sanofi-Aventis, The Medicines Company, TIMI Study Group, WebMD.
Transcript of Company, TIMI Study Group, WebMD.
Folie 1Dr. Montalescot reports research Grants to the Institution
or Consulting/Lecture Fees from ADIR, Amgen, AstraZeneca, Bayer,
Berlin Chimie AG, Boehringer Ingelheim, Bristol-Myers Squibb, Beth
Israel Deaconess Medical, Brigham Women’s Hospital, Cardiovascular
Research Foundation, Celladon, CME Resources, Daiichi- Sankyo,
Eli-Lilly, Europa, Elsevier, Fédération Française de Cardiologie,
Fondazione Anna Maria Sechi per il Cuore, Gilead, ICAN, Janssen,
Lead-Up, Menarini, Medtronic, MSD, Pfizer, Sanofi-Aventis, The
Medicines Company, TIMI Study Group, WebMD.
SCA
ACS patients PCI Recommendations Class Level
In patients with ACS, ticagrelor (180 mg loading dose, 90 mg twice daily) on top of aspirin is recommended, regardless of initial treatment strategy, including patients pre-treated with clopidogrel (which should be discontinued when ticagrelor is commenced) unless there are contra-indications.
I B
In patients with ACS undergoing PCI, prasugrel (60 mg loading dose, 10 mg daily dose) on top of aspirin is recommended for P2Y12 inhibitor-naïve patients with NSTE-ACS or initially conservatively managed STEMI if indication for PCI is established, or in STEMI patients undergoing immediate coronary catheterization unless there is a high-risk of life- threatening bleeding or other contra-indications.
I B
Recommendations Class Level
In patients with ACS treated with coronary stent implantation, DAPT with a P2Y12 inhibitor on top of aspirin is recommended for 12 months unless there are contra-indications such as excessive risk of bleeding (e.g. PRECISE-DAPT ≥25).
I A
In patients with ACS and stent implantation who are at high- risk of bleeding (e.g. PRECISE-DAPT ≥25), discontinuation of P2Y12 inhibitor therapy after 6 months should be considered.
IIa B
PLATO, ticagrelor in Hs Tn negative patients
Consider these ACS patients like SCAD patients
Montalescot G, Sabatine MS. Eur Heart J. 2016;37(4):344-52.
< 6-month DAPT in ACS/DES patients
ZEUS Trial: 63% ACS, 47% MI HBR sub-population
LEADERS-Free:HBR Patients ACS Substudy
Naber, et al. Eur Heart J 2016 (epub) **stent randomized/ 30 days DAPT
Ariotti S, et al. JACC CI 2016;9(5):426-36 *stent randomized/ 30 days DAPT
Désescalade (haut risque hémorragique)
Dose de-escalation in PRASFIT-ACS
PR U
b y
Ve rif
yN ow
400
300
200
100
0
Before and After LD
*** ***
*** *** *** *** ***
Prasugrel 20/3.75mg
Risk reduction
30 60 90 180 270 360 450
Prasugrel 60/10mg
Clopidogrel 300/75mg
N=1,363
N=13,608
Wiviott S et al. NEJM 2007;357:2001-2015 Saito S, et al. Circ J 2014; 78: 1684–92.
2.2% prasu vs. 1.7% clopi 1.9 % prasu vs. 2.2% clopi Major Bleed
ANTARCTIC a study by the ACTION Group
40% downgraded to clopi 75 4% upgraded to prasu 10
Conventional Arm :Prasugrel 5 mg
Group 1
No monitoring
PRU≥208
Group 2
Clopidogrel 75 mg/dayPrasugrel 5 mg
Primary end point (net clinical benefit) over 12 months:: Bleeding type 2,3,5 of the BARC definition andMACE (CV death, MI, urgent revascularisation, stent thrombosis, stroke)
PRU ≤85
2nd assessment and adjustment: Verifynow P2Y12 : 2 weeks ± 2 d
85<PRU<208
ANTARCTIC a study by the ACTION Group
Ischemic Endpoint CV death, MI, stent thrombosis,
urgent revascularization BARC 2,3,5
Time/drug de-escalation in TOPIC
ACS patients undergoing PCI MACE free at one month (ischemic / bleeding BARC ≥ 2)
DAPT with aspirin and newer P2Y12 blockers
Randomization
‘Unchanged DAPT’ Aspirin + Newer P2Y12 blockers
Follow-up at one year Composite primary endpoints Death, urgent revasc, stroke, BARC bleedings ≥ 2 Secondary endpoints Each component of primary endpoints All BARC bleeding, TIMI bleeding Cuisset T et al.
EHJ 2017
Time/DAPT De-escalation (towards SAPT)
1/ Thienopyridine prolongation beyond 1yr after stenting (DAPT)
Mauri L, N Engl J Med 2014;371:2155–66
DAPT prolongation after stenting Myocardial Infarction
0.74 (95% CI 0.60-0.92)
CV d
ea th
TRILOGY (prior angiogram subgroup)
3/ Adding Rivaroxaban 2.5 mg bid to Aspirin (COMPASS)
*Rates as at mean follow up of 23 months Eikelboom JW et al. N Engl J Med 2017; DOI: 10.1056/NEJMoa1709118
MACE* % HR (95% CI) p-value Aspirin 100mg OD 5.4 - - Rivaroxaban 5mg BID 4.9 0.90 (0.79-1.03) 0.12 Rivaroxaban 2.5mg BID + Aspirin 100 mg OD 4.1 0.76 (0.66-0.86) <0.001
C um
ul at
iv e
in ci
de nc
0 1 2 3
Rivaroxaban 2.5mg bid + Aspirin 100mg od Rivaroxaban 5mg bid Aspirin 100mg od
Number at risk Aspirin 100mg od 9126 7808 3860 669 Riva 5mg bid 9117 7824 3862 670 Riva 2.5mg bid + Aspirin 100mg od 9152 7904 3912 658
Year
www.escardio.org/guidelines
2017 ESC Focused Update on DAPT in Coronary Artery Disease, developed in collaboration with EACTS (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx419)
20
Algorithm for dual antiplatelet therapy (DAPT) in patients treated with percutaneous coronary intervention
2017 ESC Focused Update on DAPT in Coronary Artery Disease, developed in collaboration with EACTS (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx419)
Risk scores validated for dual antiplatelet therapy duration decision-making
21
PRECISE-DAPT score PRECISE-DAPT score Time of use At the time of coronary stenting After 12 months of uneventful DAPT DAPT duration strategies assessed
Short DAPT (3–6 months) vs. Standard/long DAPT (12–24 months)
Standard DAPT (12 months) vs. Long DAPT (30 months)
Score calculation Age ≥75 65 to <75 <65
Cigarette smoking Diabetes mellitus MI at presentation Prior PCI or prior MI Paclitaxel-eluting stent Stent diameter <3 mm CHF or LVEF <30% Vein graft stent
–2 pt –1 pt 0 pt
+1 pt +1 pt +1 pt +1 pt +1 pt +1 pt +2 pt +2 pt
Score range 0 to 100 points –2 to 10 points Decision making cut-off suggested
Score ≥25 Short DAPT Score <25 Standard/long DAPT
Score ≥2 Long DAPT Score <2 Standard DAPT
Calculator www.precisedaptscore.com www.daptstudy.org
Score Points
0 2 4 6 8 10 12 14 16 18 20 22 24 26 2830
Prior Bleeding
No Yes
Age ≤50 60 70 80 ≥90
WBC ≤5 8 10 12 14 16 18 ≥20
HB ≥2 11-5 11 10-5 ≤10
Lower platelet reactivity (Verify Now)
300
250
200
150
100
50
0
Asher E et al. Thromb Haemost 2017
P2Y12 Reaction Units (PRU)
Ticagrelor Prasugrel
Prasugre 60-mg Crushed loading Dose
Prasugrel Integral pills loading
Primary Objectives • TIMI flow grade 3 of MI culprit vessel at initial angiography • ≥70% ST-segment elevation resolution post-PCI
Pre-Hospital
Randomized
G.J. Vlachojannis et al.
APACHE Mode of administration
P. Ecollan et al.
Ticagrelor orodispersible tablet Dissolves in the mouth with or without water
https://clinicaltrials.gov/ct2/show/results/NCT02400333
A: with water; B: without water; C: NG-tube; D: IR
700 650
A ri
th m
et ic
m ea
n co
nc en
tr at
io n
(n g/
m L)
600 550 500 450 400 350 300 250 200 150 100
50 0
0 2 4 6 8 10 12 14 18 20 22 24 26 30 32 34 36 38 42 44 464028 48 5016 Time (h)
Treatment A (N=30) Treatment B (N=31) Treatment C (N=33) Treatment D (N=33)
CHAMPION-PHOENIX: IV P2Y12 inhibitor cangrelor Death/ MI/ IDR/ Stent Thrombosis within 48 Hours
cangrelor
Ev en
)
Bhatt DL et al. N Engl J Med 2013; 368: 1303-1313
TIMI Major 48h 0.1% 0.1% >0.999
TIMI Minor 48h 0.2% 0.1% 0.08
Death 48h 0.3% 0.3% 0.99
Chart1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
1
0
1
0
1
0
1
0
1
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
2
3
2
3
2
3
2
4
2
4
2
4
2
4
2
4
2
4
2
4
2
4
2
4
2
4
2
5
2
5
2
5
2
5
2
5
2
5
2
6
2
6
2
6
2
6
2
6
2
6
2
6
2
6
2
7
3
7
3
7
3
7
3
8
3
8
3
8
3
8
3
9
3
9
3
10
3
10
3
11
3
11
3
12
4
12
4
13
4
13
4
13
4
13
4
14
4
14
4
14
5
14
5
15
5
15
5
16
6
16
6
16
6
16
6
17
6
17
6
18
6
18
6
18
7
18
7
19
7
19
7
20
8
20
8
21
9
21
9
22
10
22
10
22
11
22
11
23
12
23
12
24
13
24
13
24
14
24
14
24
14
24
14
25
15
25
15
26
16
26
16
26
16
26
16
27
16
27
16
28
17
28
17
29
17
29
17
30
18
30
18
31
19
31
19
32
20
32
20
33
20
33
20
33
21
33
21
34
22
34
22
35
23
35
23
36
23
36
23
37
23
37
23
37
24
37
24
38
25
38
25
39
25
39
25
40
26
40
26
40
27
40
27
40
28
40
28
41
29
41
29
42
30
42
30
43
31
43
31
43
32
43
32
44
33
44
33
45
34
45
34
46
35
46
35
47
36
47
36
47
37
47
37
48
38
48
38
48
39
48
39
48
39
48
39
39
39
40
40
40
40
41
41
41
41
42
42
43
43
44
44
45
45
46
46
47
47
48
48
0
0
0
0
0.02
0.02
0.02
0.02
0.4
0.09
0.4
0.09
0.6
0.2
0.6
0.2
0.79
0.57
0.79
0.57
1.04
0.82
1.04
0.82
1.19
0.91
1.19
0.91
1.41
1.08
1.41
1.08
1.57
1.32
1.57
1.32
1.74
1.57
1.74
1.57
2.01
1.79
2.01
1.79
2.17
1.9
2.17
1.9
2.3
2.18
2.3
2.18
2.36
2.38
2.36
2.38
2.43
2.49
2.43
2.49
2.58
2.6
2.58
2.6
2.67
2.74
2.67
2.74
2.72
2.96
2.72
2.96
2.83
3.02
2.83
3.02
2.94
3.18
2.94
3.18
2.98
3.29
2.98
3.29
3.07
3.38
3.07
3.38
3.09
3.4
3.09
3.4
3.11
3.47
3.11
3.47
3.14
3.53
3.14
3.53
3.23
3.62
3.23
3.62
3.29
3.67
3.29
3.67
3.31
3.73
3.31
3.73
3.36
3.8
3.36
3.8
3.42
3.88
3.42
3.88
3.45
3.89
3.45
3.89
3.51
3.95
3.51
3.95
3.55
3.99
3.55
3.99
3.56
4
3.56
4
3.6
4.04
3.6
4.04
3.64
4.13
3.64
4.13
3.65
4.15
3.65
4.15
3.67
4.22
3.67
4.22
3.71
4.3
3.71
4.3
3.75
4.35
3.75
4.35
3.76
4.41
3.76
4.41
3.78
4.46
3.78
4.46
3.78
4.48
3.78
4.48
3.8
4.5
3.8
4.5
3.82
4.53
3.82
4.53
3.84
4.55
3.84
4.55
3.86
4.57
3.86
4.57
3.87
4.59
3.87
4.59
3.89
4.61
3.89
4.61
3.91
4.63
3.91
4.63
3.93
4.66
3.93
4.66
3.95
4.68
3.95
4.68
3.97
4.68
3.97
4.68
3.98
4.72
3.98
4.72
4
4.75
4
4.75
4.04
4.83
4.04
4.83
4.06
4.86
4.06
4.86
4.08
4.88
4.08
4.88
4.08
4.9
4.08
4.9
4.09
4.97
4.09
4.97
4.11
4.99
4.11
4.99
4.13
5.01
4.13
5.01
4.15
5.05
4.15
5.05
4.17
5.06
4.17
5.06
4.18
5.1
4.18
5.1
4.2
5.12
4.2
5.12
4.2
5.14
4.2
5.14
4.22
5.16
4.22
5.16
4.24
5.17
4.24
5.17
4.26
5.19
4.26
5.19
4.28
5.21
4.28
5.21
4.28
5.23
4.28
5.23
4.29
5.25
4.29
5.25
4.31
5.27
4.31
5.27
4.33
5.28
4.33
5.28
4.33
5.34
4.33
5.34
4.35
5.36
4.35
5.36
4.37
5.36
4.37
5.36
4.37
5.37
4.37
5.37
4.39
5.41
4.39
5.41
4.4
5.43
4.4
5.43
4.4
5.45
4.4
5.45
4.42
5.47
4.42
5.47
4.44
5.48
4.44
5.48
4.44
5.5
4.44
5.5
4.44
5.5
4.44
5.5
4.44
5.52
4.44
5.52
4.44
5.54
4.44
5.54
4.44
5.56
4.44
5.56
4.46
5.58
4.46
5.58
4.46
5.58
4.46
5.58
4.46
5.59
4.46
5.59
4.48
5.59
4.48
5.59
4.48
5.61
4.48
5.61
4.5
5.63
4.5
5.63
4.5
5.63
4.5
5.63
4.5
5.65
4.5
5.65
4.5
5.67
4.5
5.67
4.5
5.67
4.5
5.67
4.5
5.69
4.5
5.69
4.5
5.69
4.5
5.69
4.5
5.69
4.5
5.69
4.51
5.69
4.51
5.69
4.51
5.69
4.51
5.69
4.51
5.69
4.51
5.69
4.53
5.69
4.53
5.69
4.53
5.69
4.53
5.69
4.55
5.7
4.55
5.7
4.55
5.7
4.55
5.7
4.57
5.72
4.57
5.72
4.57
5.72
4.57
5.72
4.57
5.74
4.57
5.74
4.57
5.74
4.57
5.74
4.57
5.76
4.57
5.76
4.57
5.76
4.57
5.76
4.57
5.76
4.57
5.76
4.57
5.78
4.57
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.8
4.59
5.8
4.61
5.8
4.61
5.8
4.61
5.8
4.61
5.8
4.61
5.81
4.61
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.64
5.81
4.64
5.81
4.64
5.81
4.64
5.81
4.64
5.81
4.64
5.81
4.64
5.81
4.64
5.81
4.66
5.81
4.66
5.81
4.66
5.81
4.66
5.81
4.68
5.81
4.68
5.81
4.7
5.83
4.7
5.83
4.7
5.83
5.83
5.85
5.85
5.87
5.87
5.87
5.87
5.87
5.87
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
G5.11.1.3
acttrt
tm2ev30
event_rate
STRATUM
Censor
Survival
Failure
StdErr
Failed
CSUBJECT
left
PATIENT_AT_RISK
Conclusions
• Short DAPT after stenting (last generation DES), both in stable CAD and ACS, is a valid option, in particular if bleeding risk is increased
• Short can be as short as 1 month!
• De-escalation stratégies seem to work
• Secondary prevention relies on dual treatment when bleeding risk is low in patients with serious or recurrent ACS/MI.
Diapositive numéro 1
Diapositive numéro 10
1/ Thienopyridine prolongation beyond 1yr after stenting (DAPT)
DAPT prolongation after stenting Myocardial Infarction
Diapositive numéro 18
Diapositive numéro 20
Diapositive numéro 21
Diapositive numéro 23
CHAMPION-PHOENIX: IV P2Y12 inhibitor cangrelorDeath/ MI/ IDR/ Stent Thrombosis within 48 Hours
Auto-injector of P2Y12 antagonist
SCA
ACS patients PCI Recommendations Class Level
In patients with ACS, ticagrelor (180 mg loading dose, 90 mg twice daily) on top of aspirin is recommended, regardless of initial treatment strategy, including patients pre-treated with clopidogrel (which should be discontinued when ticagrelor is commenced) unless there are contra-indications.
I B
In patients with ACS undergoing PCI, prasugrel (60 mg loading dose, 10 mg daily dose) on top of aspirin is recommended for P2Y12 inhibitor-naïve patients with NSTE-ACS or initially conservatively managed STEMI if indication for PCI is established, or in STEMI patients undergoing immediate coronary catheterization unless there is a high-risk of life- threatening bleeding or other contra-indications.
I B
Recommendations Class Level
In patients with ACS treated with coronary stent implantation, DAPT with a P2Y12 inhibitor on top of aspirin is recommended for 12 months unless there are contra-indications such as excessive risk of bleeding (e.g. PRECISE-DAPT ≥25).
I A
In patients with ACS and stent implantation who are at high- risk of bleeding (e.g. PRECISE-DAPT ≥25), discontinuation of P2Y12 inhibitor therapy after 6 months should be considered.
IIa B
PLATO, ticagrelor in Hs Tn negative patients
Consider these ACS patients like SCAD patients
Montalescot G, Sabatine MS. Eur Heart J. 2016;37(4):344-52.
< 6-month DAPT in ACS/DES patients
ZEUS Trial: 63% ACS, 47% MI HBR sub-population
LEADERS-Free:HBR Patients ACS Substudy
Naber, et al. Eur Heart J 2016 (epub) **stent randomized/ 30 days DAPT
Ariotti S, et al. JACC CI 2016;9(5):426-36 *stent randomized/ 30 days DAPT
Désescalade (haut risque hémorragique)
Dose de-escalation in PRASFIT-ACS
PR U
b y
Ve rif
yN ow
400
300
200
100
0
Before and After LD
*** ***
*** *** *** *** ***
Prasugrel 20/3.75mg
Risk reduction
30 60 90 180 270 360 450
Prasugrel 60/10mg
Clopidogrel 300/75mg
N=1,363
N=13,608
Wiviott S et al. NEJM 2007;357:2001-2015 Saito S, et al. Circ J 2014; 78: 1684–92.
2.2% prasu vs. 1.7% clopi 1.9 % prasu vs. 2.2% clopi Major Bleed
ANTARCTIC a study by the ACTION Group
40% downgraded to clopi 75 4% upgraded to prasu 10
Conventional Arm :Prasugrel 5 mg
Group 1
No monitoring
PRU≥208
Group 2
Clopidogrel 75 mg/dayPrasugrel 5 mg
Primary end point (net clinical benefit) over 12 months:: Bleeding type 2,3,5 of the BARC definition andMACE (CV death, MI, urgent revascularisation, stent thrombosis, stroke)
PRU ≤85
2nd assessment and adjustment: Verifynow P2Y12 : 2 weeks ± 2 d
85<PRU<208
ANTARCTIC a study by the ACTION Group
Ischemic Endpoint CV death, MI, stent thrombosis,
urgent revascularization BARC 2,3,5
Time/drug de-escalation in TOPIC
ACS patients undergoing PCI MACE free at one month (ischemic / bleeding BARC ≥ 2)
DAPT with aspirin and newer P2Y12 blockers
Randomization
‘Unchanged DAPT’ Aspirin + Newer P2Y12 blockers
Follow-up at one year Composite primary endpoints Death, urgent revasc, stroke, BARC bleedings ≥ 2 Secondary endpoints Each component of primary endpoints All BARC bleeding, TIMI bleeding Cuisset T et al.
EHJ 2017
Time/DAPT De-escalation (towards SAPT)
1/ Thienopyridine prolongation beyond 1yr after stenting (DAPT)
Mauri L, N Engl J Med 2014;371:2155–66
DAPT prolongation after stenting Myocardial Infarction
0.74 (95% CI 0.60-0.92)
CV d
ea th
TRILOGY (prior angiogram subgroup)
3/ Adding Rivaroxaban 2.5 mg bid to Aspirin (COMPASS)
*Rates as at mean follow up of 23 months Eikelboom JW et al. N Engl J Med 2017; DOI: 10.1056/NEJMoa1709118
MACE* % HR (95% CI) p-value Aspirin 100mg OD 5.4 - - Rivaroxaban 5mg BID 4.9 0.90 (0.79-1.03) 0.12 Rivaroxaban 2.5mg BID + Aspirin 100 mg OD 4.1 0.76 (0.66-0.86) <0.001
C um
ul at
iv e
in ci
de nc
0 1 2 3
Rivaroxaban 2.5mg bid + Aspirin 100mg od Rivaroxaban 5mg bid Aspirin 100mg od
Number at risk Aspirin 100mg od 9126 7808 3860 669 Riva 5mg bid 9117 7824 3862 670 Riva 2.5mg bid + Aspirin 100mg od 9152 7904 3912 658
Year
www.escardio.org/guidelines
2017 ESC Focused Update on DAPT in Coronary Artery Disease, developed in collaboration with EACTS (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx419)
20
Algorithm for dual antiplatelet therapy (DAPT) in patients treated with percutaneous coronary intervention
2017 ESC Focused Update on DAPT in Coronary Artery Disease, developed in collaboration with EACTS (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx419)
Risk scores validated for dual antiplatelet therapy duration decision-making
21
PRECISE-DAPT score PRECISE-DAPT score Time of use At the time of coronary stenting After 12 months of uneventful DAPT DAPT duration strategies assessed
Short DAPT (3–6 months) vs. Standard/long DAPT (12–24 months)
Standard DAPT (12 months) vs. Long DAPT (30 months)
Score calculation Age ≥75 65 to <75 <65
Cigarette smoking Diabetes mellitus MI at presentation Prior PCI or prior MI Paclitaxel-eluting stent Stent diameter <3 mm CHF or LVEF <30% Vein graft stent
–2 pt –1 pt 0 pt
+1 pt +1 pt +1 pt +1 pt +1 pt +1 pt +2 pt +2 pt
Score range 0 to 100 points –2 to 10 points Decision making cut-off suggested
Score ≥25 Short DAPT Score <25 Standard/long DAPT
Score ≥2 Long DAPT Score <2 Standard DAPT
Calculator www.precisedaptscore.com www.daptstudy.org
Score Points
0 2 4 6 8 10 12 14 16 18 20 22 24 26 2830
Prior Bleeding
No Yes
Age ≤50 60 70 80 ≥90
WBC ≤5 8 10 12 14 16 18 ≥20
HB ≥2 11-5 11 10-5 ≤10
Lower platelet reactivity (Verify Now)
300
250
200
150
100
50
0
Asher E et al. Thromb Haemost 2017
P2Y12 Reaction Units (PRU)
Ticagrelor Prasugrel
Prasugre 60-mg Crushed loading Dose
Prasugrel Integral pills loading
Primary Objectives • TIMI flow grade 3 of MI culprit vessel at initial angiography • ≥70% ST-segment elevation resolution post-PCI
Pre-Hospital
Randomized
G.J. Vlachojannis et al.
APACHE Mode of administration
P. Ecollan et al.
Ticagrelor orodispersible tablet Dissolves in the mouth with or without water
https://clinicaltrials.gov/ct2/show/results/NCT02400333
A: with water; B: without water; C: NG-tube; D: IR
700 650
A ri
th m
et ic
m ea
n co
nc en
tr at
io n
(n g/
m L)
600 550 500 450 400 350 300 250 200 150 100
50 0
0 2 4 6 8 10 12 14 18 20 22 24 26 30 32 34 36 38 42 44 464028 48 5016 Time (h)
Treatment A (N=30) Treatment B (N=31) Treatment C (N=33) Treatment D (N=33)
CHAMPION-PHOENIX: IV P2Y12 inhibitor cangrelor Death/ MI/ IDR/ Stent Thrombosis within 48 Hours
cangrelor
Ev en
)
Bhatt DL et al. N Engl J Med 2013; 368: 1303-1313
TIMI Major 48h 0.1% 0.1% >0.999
TIMI Minor 48h 0.2% 0.1% 0.08
Death 48h 0.3% 0.3% 0.99
Chart1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
1
0
1
0
1
0
1
0
1
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
1
3
2
3
2
3
2
3
2
4
2
4
2
4
2
4
2
4
2
4
2
4
2
4
2
4
2
4
2
5
2
5
2
5
2
5
2
5
2
5
2
6
2
6
2
6
2
6
2
6
2
6
2
6
2
6
2
7
3
7
3
7
3
7
3
8
3
8
3
8
3
8
3
9
3
9
3
10
3
10
3
11
3
11
3
12
4
12
4
13
4
13
4
13
4
13
4
14
4
14
4
14
5
14
5
15
5
15
5
16
6
16
6
16
6
16
6
17
6
17
6
18
6
18
6
18
7
18
7
19
7
19
7
20
8
20
8
21
9
21
9
22
10
22
10
22
11
22
11
23
12
23
12
24
13
24
13
24
14
24
14
24
14
24
14
25
15
25
15
26
16
26
16
26
16
26
16
27
16
27
16
28
17
28
17
29
17
29
17
30
18
30
18
31
19
31
19
32
20
32
20
33
20
33
20
33
21
33
21
34
22
34
22
35
23
35
23
36
23
36
23
37
23
37
23
37
24
37
24
38
25
38
25
39
25
39
25
40
26
40
26
40
27
40
27
40
28
40
28
41
29
41
29
42
30
42
30
43
31
43
31
43
32
43
32
44
33
44
33
45
34
45
34
46
35
46
35
47
36
47
36
47
37
47
37
48
38
48
38
48
39
48
39
48
39
48
39
39
39
40
40
40
40
41
41
41
41
42
42
43
43
44
44
45
45
46
46
47
47
48
48
0
0
0
0
0.02
0.02
0.02
0.02
0.4
0.09
0.4
0.09
0.6
0.2
0.6
0.2
0.79
0.57
0.79
0.57
1.04
0.82
1.04
0.82
1.19
0.91
1.19
0.91
1.41
1.08
1.41
1.08
1.57
1.32
1.57
1.32
1.74
1.57
1.74
1.57
2.01
1.79
2.01
1.79
2.17
1.9
2.17
1.9
2.3
2.18
2.3
2.18
2.36
2.38
2.36
2.38
2.43
2.49
2.43
2.49
2.58
2.6
2.58
2.6
2.67
2.74
2.67
2.74
2.72
2.96
2.72
2.96
2.83
3.02
2.83
3.02
2.94
3.18
2.94
3.18
2.98
3.29
2.98
3.29
3.07
3.38
3.07
3.38
3.09
3.4
3.09
3.4
3.11
3.47
3.11
3.47
3.14
3.53
3.14
3.53
3.23
3.62
3.23
3.62
3.29
3.67
3.29
3.67
3.31
3.73
3.31
3.73
3.36
3.8
3.36
3.8
3.42
3.88
3.42
3.88
3.45
3.89
3.45
3.89
3.51
3.95
3.51
3.95
3.55
3.99
3.55
3.99
3.56
4
3.56
4
3.6
4.04
3.6
4.04
3.64
4.13
3.64
4.13
3.65
4.15
3.65
4.15
3.67
4.22
3.67
4.22
3.71
4.3
3.71
4.3
3.75
4.35
3.75
4.35
3.76
4.41
3.76
4.41
3.78
4.46
3.78
4.46
3.78
4.48
3.78
4.48
3.8
4.5
3.8
4.5
3.82
4.53
3.82
4.53
3.84
4.55
3.84
4.55
3.86
4.57
3.86
4.57
3.87
4.59
3.87
4.59
3.89
4.61
3.89
4.61
3.91
4.63
3.91
4.63
3.93
4.66
3.93
4.66
3.95
4.68
3.95
4.68
3.97
4.68
3.97
4.68
3.98
4.72
3.98
4.72
4
4.75
4
4.75
4.04
4.83
4.04
4.83
4.06
4.86
4.06
4.86
4.08
4.88
4.08
4.88
4.08
4.9
4.08
4.9
4.09
4.97
4.09
4.97
4.11
4.99
4.11
4.99
4.13
5.01
4.13
5.01
4.15
5.05
4.15
5.05
4.17
5.06
4.17
5.06
4.18
5.1
4.18
5.1
4.2
5.12
4.2
5.12
4.2
5.14
4.2
5.14
4.22
5.16
4.22
5.16
4.24
5.17
4.24
5.17
4.26
5.19
4.26
5.19
4.28
5.21
4.28
5.21
4.28
5.23
4.28
5.23
4.29
5.25
4.29
5.25
4.31
5.27
4.31
5.27
4.33
5.28
4.33
5.28
4.33
5.34
4.33
5.34
4.35
5.36
4.35
5.36
4.37
5.36
4.37
5.36
4.37
5.37
4.37
5.37
4.39
5.41
4.39
5.41
4.4
5.43
4.4
5.43
4.4
5.45
4.4
5.45
4.42
5.47
4.42
5.47
4.44
5.48
4.44
5.48
4.44
5.5
4.44
5.5
4.44
5.5
4.44
5.5
4.44
5.52
4.44
5.52
4.44
5.54
4.44
5.54
4.44
5.56
4.44
5.56
4.46
5.58
4.46
5.58
4.46
5.58
4.46
5.58
4.46
5.59
4.46
5.59
4.48
5.59
4.48
5.59
4.48
5.61
4.48
5.61
4.5
5.63
4.5
5.63
4.5
5.63
4.5
5.63
4.5
5.65
4.5
5.65
4.5
5.67
4.5
5.67
4.5
5.67
4.5
5.67
4.5
5.69
4.5
5.69
4.5
5.69
4.5
5.69
4.5
5.69
4.5
5.69
4.51
5.69
4.51
5.69
4.51
5.69
4.51
5.69
4.51
5.69
4.51
5.69
4.53
5.69
4.53
5.69
4.53
5.69
4.53
5.69
4.55
5.7
4.55
5.7
4.55
5.7
4.55
5.7
4.57
5.72
4.57
5.72
4.57
5.72
4.57
5.72
4.57
5.74
4.57
5.74
4.57
5.74
4.57
5.74
4.57
5.76
4.57
5.76
4.57
5.76
4.57
5.76
4.57
5.76
4.57
5.76
4.57
5.78
4.57
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.78
4.59
5.8
4.59
5.8
4.61
5.8
4.61
5.8
4.61
5.8
4.61
5.8
4.61
5.81
4.61
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.62
5.81
4.64
5.81
4.64
5.81
4.64
5.81
4.64
5.81
4.64
5.81
4.64
5.81
4.64
5.81
4.64
5.81
4.66
5.81
4.66
5.81
4.66
5.81
4.66
5.81
4.68
5.81
4.68
5.81
4.7
5.83
4.7
5.83
4.7
5.83
5.83
5.85
5.85
5.87
5.87
5.87
5.87
5.87
5.87
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
5.89
G5.11.1.3
acttrt
tm2ev30
event_rate
STRATUM
Censor
Survival
Failure
StdErr
Failed
CSUBJECT
left
PATIENT_AT_RISK
Conclusions
• Short DAPT after stenting (last generation DES), both in stable CAD and ACS, is a valid option, in particular if bleeding risk is increased
• Short can be as short as 1 month!
• De-escalation stratégies seem to work
• Secondary prevention relies on dual treatment when bleeding risk is low in patients with serious or recurrent ACS/MI.
Diapositive numéro 1
Diapositive numéro 10
1/ Thienopyridine prolongation beyond 1yr after stenting (DAPT)
DAPT prolongation after stenting Myocardial Infarction
Diapositive numéro 18
Diapositive numéro 20
Diapositive numéro 21
Diapositive numéro 23
CHAMPION-PHOENIX: IV P2Y12 inhibitor cangrelorDeath/ MI/ IDR/ Stent Thrombosis within 48 Hours
Auto-injector of P2Y12 antagonist
