ESC Congress 2011

8/3/2019 ESC Congress 2011

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Prof. Dr. med. Sigmund SilberFACC, FESC

Cardiology Practice and HospitalMunich, Germany

Outpatient Practice Heart Center at the Isar


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10th Anniversaryof CCP !


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1. Impressions and General Informations

2. Update on Indications for Revascularization

3. Update on Drug-Eluting Stents

4. Update on new Oral Anticoagulation in ACS

5. Update on new Oral Antiplatelet Drugs in ACS

- Take Home Messages for Practitioners -Coronary Artery Disease


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- Take Home Messages for Practitioners -Coronary Artery Disease (CAD)

Sources for the Messages:

Hot Lines / Clinical Trial Updates / Clinical Registry Highlights

New Guidelines

Preorganized Sessions Original Contributions (oral presentations / posters)


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Drugs /

Epidemiology

Rhythm PCI Valvular

n = 23 n = 9 n = 5 n = 2


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New Guidelines


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New Guidelinesfor Myocardial Revascularization

ESC Stockholm29th of August 2010


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EHJ, 31: 2501-2555, (2010)


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Only 1 year laterEHJ-online published August 26, 2011


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Criteria for high risk with indication for

invasive management in patients with NSTE-ACS

European Heart JournalAdvance Access published August 26, 2011

High-sensitivityTroponin


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Rapid rule-out of ACS with high-sensitivity troponin.

European Heart JournalAdvance Access published August 26, 2011


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The new ESC NSTE-ACS Guidelines arehelpful for decision of invasive vs. early ruleout regimen.

Elderly patients with NSTE-ACS often have nobenefit from an invasive approach.

Take Home Messages for Practitioners:Revascularization in NSTE-ACS


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NSTE-ACS

Stable CAD


4. Update on Oral Anticoagulation in ACS

5. Update on new Oral Antiplatelet Drugs



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EHJ, 31: 2501-2555, (2010)

Bypass Surgery (CABG) versus in Patients with stable CAD


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In patients with stable CAD, complex anatomy with a SYNTAXscore 33, bypass surgery should be strongly considered.

Since the CREDO-Kyoto study was not randomized, patients witha low SYNTAX score have further to be evaluated.

Take Home Messages for Practitioners:Revascularization in stable CAD


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5. Update on new new Oral Antiplatelet Drugs in ACS



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RAVEL-Study(ESC, Stockholm, September 2001)

Bare Metal Stent Cypher-Stent

Patients n=120 n=118

Results after 12 Months:

Restenosis: 26,0% 0%


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Mortality


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EHJ, 31: 2501-2555, (2010)


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R d d DES


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EHJ, 31: 2501-2555, (2010)

Recommended DES


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Stent ThrombosisEvidence from Clinical Trials

Stephan Windecker

Department of Cardiology

Swiss Cardiovascular Center and Clinical Trials Unit Bern

Bern University Hospital, Switzerland

Definite Stent Thrombosis With DES:


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0 1 2 3 4

Time since PCI in years

0

1

2

3

4

5

Cumulati

veincidence,

%

Months 1 12 24 36 48

Cumulative incidence, % 1.2 1.6 2.1 2.7 3.3

Patients at risk 7538 7210 5164 2790 1051

Incidence density

1.0 / 100 pt years

3.3%

3.5

Definite Stent Thrombosis With DES:Bern - Rotterdam Cohort Study

Daemen J et al. Lancet2007;369:667-78

192 ST casesin a cohortof 8.146 patients

Updated

Follow-up to

4 Years


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Very Late

Stent

Thrombosis

Bavry A et al. Lancet2008

Prevention of Very Late ST New Stent Technology


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BiodegradablePolymer

abluminal only

After releaseof polymer

StentStrut

StentStrut

Polymer

coating

New GenerationDES

EndothelialProgenitor Cell Capture

Biodegradable Polymers Polymer Free Surface Bioabsorbale Stents

Prevention of Very Late ST New Stent TechnologyFirst Generation

DES
http://circ.ahajournals.org/content/vol102/issue4/images/large/hc2904279001.jpeg


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RESET Trial


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RESET Trial(Randomized Evaluation of Sirolimus-eluting versus Everolimus-eluting stent Trial)

Imaging Sub-studies at 8-12 months:

Angiography (500 patients), IVUS/OCT (120 patients), Endothelial function (100 patients)

(Scheduled follow-up angiography by local site protocol was allowed beyond 240 days. )

Primar Endpoints and Sample Si e Calc lation


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Primary Endpoints and Sample Size Calculation


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Death/Myocardial Infarction


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Definite/Probable Stent Thrombosis


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COMPARE: First Definite Stent Thrombosis @ 2 yr


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COMPARE: First Definite Stent Thrombosis @ 2 yr(Definite according to ARC)

2.7 %

0.6 %

Taxus

XienceP < 0.0001 (log-rank test)

RR = 0.21 (0.08-0.55)

0.3 %

2.0 %

1.7 %

2.1 %

Definite or Probable ST Landmark Analysis


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4%

2%

0%

Time after Initial Procedure (days)

C

umulativeIncidence

ofDef/ProbThrom

bosis

Endeavor 732 732 719 716 710 699 688 684 680

Taxus 734 734 721 718 714 701 690 681 674

360 450 540 630 720 810 900 990 1080

0.1%

1.6%

1.5%

1-3 year HR0.09 [0.01, 0.71]

P = 0.004

Endeavor Zotarolimus-eluting

Taxus Paclitaxel-eluting

Definite or Probable ST Landmark Analysis

1-3 Years ENDEAVOR IVLeon M et al. JACC Intv2010;3:104350

Comparison of Everolimus-Eluting and


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15%

0%

Cumul

ativeIncidenceofEven

ts

5%

10%

0 6 12 18 24

1.9%

1.0%

Resolute ZES (N = 1140)

Xience V EES (N = 1152)

Months

P= 0.07

Definite or Probable ST Through 2 Years

p g

Zotarolimus-Eluting Resolute StentSerruys PW et al. N Engl J Med2010

Silber S et al. Lancet2011

P= 0.05

1.6%

0.5%

1.0%0.5%

4.4%4.9%

-1.0%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

ZES EES

Cum

ulativeincidence

ST associated Not ST associated

5.4% 5.4%P = 1.0

P = 0.57

P = 0.23

Cardiac Death or MI


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Conclusion:No significant differences in tissue coverage, malapposition orlumen/stent areas and volumes were detected by OCT between thehydrophilic-polymer coated Resolute Zotarolimus-eluting and the

fluoropolymer-coated Everolimus-eluting stent 13 months follow-up.


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Drug-eluting stents are the default stenting strategy - unlessthere are concerns or contraindications to prolonged dualantiplatelet therapy.

Very late stent thrombosis is somewhat more frequent with firstgeneration DES.

Since with newer generation DES stent thrombosis has becomea minor issue, newer generation DES should be preferred.

Take Home Messages for Practitioners:Drug-Eluting Stents (DES)


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Although oral anticoagulation with new drugs were the highlight

at the ESC 2011 in patients with atrial fibrillation, positive effectshave not been shown in patients with ACS.

In addition to the guideline-oriented dual anti-platelet ACStreatment, the addition of the oral factor Xa inhibitor Darexabanshowed an increased risk of bleeding without a reduction of

ischemic events. We have to wait for the results of the ongoing ATLAS trial.

Take Home Messages for Practitioners:Oral Anticoagulation in ACS


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P2Y12 Inhibitors


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STEMI


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EHJ, 31: 2501-2555, (2010)

Same level ofrecommendation

NSTE-ACS


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EHJ, 31: 2501-2555, (2010)

Different levels ofrecommendation


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Ticagrelor

Oral Antiplatelet Agents in NSTE-ACS


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p g

European Heart Journal

Advance Access published August 26, 2011

Oral Antiplatelet Agents in NSTE-ACS


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p g

European Heart Journal

Advance Access published August 26, 2011


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In the new ESC NSTE-ACS guidelines, Prasugrel was upgradedfrom IIa B (in 2010) to I B.

Now, the level of recommendation for Prasugrel and Ticagrelor isthe same for both drugs in NSTE-ACS and STEMI.

Clopidogrel is now recommended only for patients who cannot

receive Prasugrel or Ticagrelor.

Take Home Messages for Practitioners:New Oral Antiplatelet Drugs in ACS


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Munich is a great and lovely city

Munich is waiting for you !

Take Home Messages for Practitioners:- the last one -

ESC Congress 2011

Documents

Transcript of ESC Congress 2011