PRACTICAL RECOMMENDATIONS ON ANTI- THROMBOTIC TREATMENT IN PATIENTS TREATED WITH DRUG-ELUTING STENTS...

PRACTICAL RECOMMENDATIONS ON ANTI-PRACTICAL RECOMMENDATIONS ON ANTI-

THROMBOTIC TREATMENT IN PATIENTS THROMBOTIC TREATMENT IN PATIENTS

TREATED WITH DRUG-ELUTING STENTSTREATED WITH DRUG-ELUTING STENTS

Giuseppe Biondi-ZoccaiGiuseppe Biondi-Zoccai

Ospedale S. Giovanni Battista “Molinette”

Università di Torino

Convegno Regionale Piemonte e Valle d’Aosta “La morte improvvisa dal neonato all’adulto: un evento sempre inevitabile?” - Torino, 28-29 Settembre 2007 (h14.45-15.00)

Learning objectives

I. Goals of antithrombotic treatment in patients undergoing drug-eluting stenting (DES)

II. Pathophysiologic and clinical data on thrombotic risk in patients with DES

III. Practical recommendations

Learning objectives


II. Clinical data on thrombotic risk in patients with DES


Benefits of prolonged dual antiplatelet treatement

Eisenstein et al, JAMA 2006

1501 patients treated with DES: no data on stent thrombosis (ST)

Incidence and predictors of stent thrombosis in DES

Iakovou et al, JAMA 2006

2229 patients treated with DES: 0.6% subacute ST; 0.7% late ST; 1.3% total ST at 9 months

!!!

!!!

!!!

Is dual antiplatelet therapy truly

beneficial beyond 6 months?

Airoldi et al, Circulation 2007

3021 patients treated with DES: 1.4% ST <6 months; 0.5% ST 6-18 months ; 1.9% total ST at 18 months

Learning objectives


II. Pathophysiologic and clinical data on thrombotic risk in patients with DES


Resources for practical recommendations

I. Grines CL, Bonow RO, Casey DE Jr, et al; American Heart Association; American College of Cardiology; Society for Cardiovascular Angiography and Interventions; American College of Surgeons; American Dental Association; American College of Physicians. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation. 2007 Feb 13;115(6):813-8.

II. Hodgson JM, Stone GW, Lincoff AM, et al; Society for Cardiovascular Angiography and Interventions. Late stent thrombosis: considerations and practical advice for the use of drug-eluting stents: a report from the Society for Cardiovascular Angiography and Interventions Drug-eluting Stent Task Force. Catheter Cardiovasc Interv. 2007 Feb 15;69(3):327-33.

III. Silber S, Albertsson P, Aviles FF, et al; Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J. 2005 Apr;26(8):804-47.

IV. Steinhubl SR, Berger PB, Mann JT 3rd, et al; CREDO Investigators. Clopidogrel for the Reduction of Events During Observation. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA. 2002 Nov 20;288(19):2411-20.

Resources for practical recommendations

I. Grines CL, Bonow RO, Casey DE Jr, et al; American Heart Association; American College of Cardiology; Society for Cardiovascular Angiography and Interventions; American College of Surgeons; American Dental Association; American College of Physicians. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation. 2007 Feb 13;115(6):813-8.

II. Hodgson JM, Stone GW, Lincoff AM, et al; Society for Cardiovascular Angiography and Interventions. Late stent thrombosis: considerations and practical advice for the use of drug-eluting stents: a report from the Society for Cardiovascular Angiography and Interventions Drug-eluting Stent Task Force. Catheter Cardiovasc Interv. 2007 Feb 15;69(3):327-33.

III. Silber S, Albertsson P, Aviles FF, et al; Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J. 2005 Apr;26(8):804-47.

IV. Steinhubl SR, Berger PB, Mann JT 3rd, et al; CREDO Investigators. Clopidogrel for the Reduction of Events During Observation. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA. 2002 Nov 20;288(19):2411-20.

12m of

ASA+TNP

12m of

ASA+TNP

6-12m of

ASA+TNP

12m of

ASA+TNPASA=aspirin; TNP=thienopyridine (clopidogrel or ticlopidine)

66-y-o woman with effort angina

PTCA with non-overlapping bare-metal stents in right coronary artery

Optimal antithrombotic Rx?

Life-long aspirin

Life-long aspirin, TNP for 1 month

Life-long aspirin, TNP for >6-12 months

Life-long aspirin, TNP for 12-18 months

TNP=thienopyridine (clopidogrel or ticlopidine)

58-y-o man with silent ischemia

PTCA with multiple small diameter paclitaxel-eluting stents in distal

right coronary branches


Life-long aspirin





71-y-o woman with unstable angina

PTCA with sirolimus-eluting stents in unprotected distal left main and proximal left anterior descending


Life-long aspirin





56-y-o man with de novo ST-elevation myocardial infarction

PTCA with bare-metal stent in mid left anterior descending


Life-long aspirin





Take home messages

1. Not all patients are born equal

2. Both accurate choice of revascularization strategy (CABG, PCI with BMS, PCI with DES, or none) AND

aggressive medical RX are pivotal

3. Avoid aggressive and long-term dual

antiplatelet therapy for all patients, as every

single one should be handled differently

All from

All different

More humbly…DIAGNOSISDIAGNOSIS PCIPCI THERAPYTHERAPY

CSA

- Life-long aspirin

POBA Life-long aspirin

BMS Life-long aspirin, TNP for 1 month

DES Life-long aspirin, TNP for >6-12 months

NSTEACS

- Life-long aspirin, TNP for 12-18 months

POBA Life-long aspirin, TNP for 12-18 months

BMS Life-long aspirin, TNP for 12-18 months

DES Life-long aspirin, TNP for 12-18 months

STEMI

- Life-long aspirin, TNP for 1 month

POBA Life-long aspirin, TNP for 1 month

BMS Life-long aspirin, TNP for 1 month

DES Life-long aspirin, TNP for >6-12 months

BMS=bare-metal stent; CSA=chronic stable angina; DES=drug-eluting stent; NSTEACS=non-ST-elevation acute coronary syndromes; PCI=percutaneous coronary intervention; POBA=pure-only balloon angioplasty;

STEMI=ST-elevation myocardial infarction; TNP=thienopyridine (clopidogrel or ticlopidine)

For further slides on these topics please feel free to visit the metcardio.org website:

http://www.metcardio.org/slides.html









PRACTICAL RECOMMENDATIONS ON ANTI- THROMBOTIC TREATMENT IN PATIENTS TREATED WITH DRUG-ELUTING STENTS...

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