Practical recommendations on anti thrombotic treatment in patients treated with drug eluting stents
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PRACTICAL RECOMMENDATIONS ON ANTI-THROMBOTIC TREATMENT IN PATIENTS TREATED WITH DRUG-ELUTING STENTS. Giuseppe Biondi-Zoccai Ospedale S. Giovanni Battista “Molinette” Università di Torino.

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Practical recommendations on anti thrombotic treatment in patients treated with drug eluting stents

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

Giuseppe 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
Learning objectives PATIENTS TREATED WITH DRUG-ELUTING STENTS

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

  • Pathophysiologic and clinical data on thrombotic risk in patients with DES

  • Practical recommendations


Learning objectives1
Learning objectives PATIENTS TREATED WITH DRUG-ELUTING STENTS

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

  • Pathophysiologic and clinical data on thrombotic risk in patients with DES

  • Practical recommendations


Learning objectives2
Learning objectives PATIENTS TREATED WITH DRUG-ELUTING STENTS

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

  • Clinical data on thrombotic risk in patients with DES

  • Practical recommendations


Benefits of prolonged dual antiplatelet treatement
Benefits of prolonged dual antiplatelet treatement PATIENTS TREATED WITH DRUG-ELUTING STENTS

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

Eisenstein et al, JAMA 2006


Incidence and predictors of stent thrombosis in des
Incidence and predictors of stent thrombosis in DES PATIENTS TREATED WITH DRUG-ELUTING STENTS

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

!!!

!!!

!!!

Iakovou et al, JAMA 2006


Is dual antiplatelet therapy truly beneficial beyond 6 months
Is dual antiplatelet therapy truly beneficial beyond 6 months?

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

Airoldi et al, Circulation 2007


Learning objectives3
Learning objectives months?

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

  • Pathophysiologic and clinical data on thrombotic risk in patients with DES

  • Practical recommendations


Resources for practical recommendations
Resources for practical recommendations months?

  • 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.

  • 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.

  • 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.

  • 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 recommendations1
Resources for practical recommendations months?

  • 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.

  • 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.

  • 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.

  • 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+TNP

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


66 y o woman with effort angina
66-y-o woman with effort angina months?

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


Optimal antithrombotic rx
Optimal antithrombotic Rx? months?

TNP=thienopyridine (clopidogrel or ticlopidine)


Optimal antithrombotic rx1
Optimal antithrombotic Rx? months?

TNP=thienopyridine (clopidogrel or ticlopidine)


58 y o man with silent ischemia
58-y-o man with silent ischemia months?

PTCA with multiple small diameter paclitaxel-eluting stents in distal right coronary branches


Optimal antithrombotic rx2
Optimal antithrombotic Rx? months?

TNP=thienopyridine (clopidogrel or ticlopidine)


Optimal antithrombotic rx3
Optimal antithrombotic Rx? months?

TNP=thienopyridine (clopidogrel or ticlopidine)


71 y o woman with unstable angina
71-y-o woman with unstable angina months?

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


Optimal antithrombotic rx4
Optimal antithrombotic Rx? months?

TNP=thienopyridine (clopidogrel or ticlopidine)


Optimal antithrombotic rx5
Optimal antithrombotic Rx? months?

TNP=thienopyridine (clopidogrel or ticlopidine)


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

PTCA with bare-metal stent in mid left anterior descending


Optimal antithrombotic rx6
Optimal antithrombotic Rx? months?

TNP=thienopyridine (clopidogrel or ticlopidine)


Optimal antithrombotic rx7
Optimal antithrombotic Rx? months?

TNP=thienopyridine (clopidogrel or ticlopidine)




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
More humbly… for all patients, as every single one should be handled differently

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


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