Optimal DAPT choices for high-bleeding risk patients · ESC 2014 ESC/EACTS Guidelines on myocardial...
Transcript of Optimal DAPT choices for high-bleeding risk patients · ESC 2014 ESC/EACTS Guidelines on myocardial...
Optimal DAPT choices for high-bleeding risk patients
A challenging patient with oral anticoagulant therapyIs there an alternative strategy?
Christian Spaulding, MD, PhD, FACC, FESC
Hôpital Européen Georges Pompidou, Paris, France
Speaker's name: Christian Spaulding
I have the following potential conflicts of interest to report:
Receipt of honoraria or consultation fees:
• Abiomed, Zoll, Medtronic, Medpass, Astra-Zeneca, Cordis, Servier, Lead-Up, Bayer, the Medicines Company, Eli Lilly, WebMD.
Research grant from the French Ministry of Health
Potential conflicts of interest
The differences between French and Swiss
interventional cardiologists
Mr. JCA - 71 year old (born 1945)
Ad-hoc PCI or planned procedure ?Radial or femoral approach ?Which stent : DES or BMS?
Duration of DAPT?
Multidisciplinary approach
• The case clearly needs a consensus between the interventional cardiologist, the referring cardiologist, the surgeon and the anesthesiologist, and the patient !
Planned PCI procedure with pre-defined strategy after a consensus meeting
Meta-analysis of MACE in randomised studies comparing radial and femoral access for PCI
Hamon M et al, EuroIntervention 2013;8:1242-1251 MACE: major adverse cardiac eventsPCI: percutaneous coronary intervention
Radial approach if technically feasible by a trained operator
DES >>> BMS
Mehran R et al, Lancet 2013; 382: 1714–22
ESC 2014 ESC/EACTS Guidelines on myocardial revascularization
Windecker S et al, Eur Heart J. 2014;35:2541-619
Duration of DAPT ?
2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease
PCI: percutaneous coronary intervention, DAPT: dual antiplatelet therapy, DES: drug eluting stent, BMS: bare metal stent, mo: month, y: year
Levine GN et al, J Am Coll Cardiol, 2016
Joint consensus document on the management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or
undergoing percutaneous coronary or valve interventions
Lip YH et al, EHJ 2016
5.6
2.5
1.9
2.5
5.0
1.21.6
1.0 1.0
1.5
2.9
0.4
0
2
4
6
8
Any Death Cardiac Death TV related MI cd TLR TLF ST
%
OAC, N=160
Non-OAC, N=3411
P=0.002 P=0.09 P=0.22 P=0.31 P=0.18P=0.14
E-ULTIMASTER – Global registry
Clinical outcomes at 1 year
Patients on OAC
Different DAPT regiment
2.9 2.9
0.0
5.7 5.7
0.0
4.0 4.0
0.0
4.0 4.0
0.00.0 0.0
5.9 5.9 5.9
0.0
8.4
3.6
2.4
3.6
7.2
1.2
0
2
4
6
8
10
12
Death MI TLR TLF Bleeding ST
No DAPT at
Discharge +
Stopped <1m,
never resumed,
N°=35
No DAPT at
Discharge + Stopped
<1m, resumed DAPT
before 3m, N°=25
Stopped DAPT
between 1 and 3
months, N°=17
Continued DAPT
after 3 months,
N°=83
NS
%
An alternative strategy
• Planned PCI procedure after consensus meeting
• Radial approach
• DES
• Duration of DAPT and date of surgery:– According to the guidelines: 3 to 6 months
– One month ? : need for randomized data on DES and short duration of DAPT
• Randomize in MASTER DAPT !