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Doppia antiaggregazione dopo impianto di DES: prolungata... ma non troppo?

Doppia antiaggregazione dopo impianto di DES: prolungata... ma non troppo?. UO Cardiologia ASL 9 Grosseto. Ugo Limbruno. Conflict of Interest: c onsulting for ABBOTT, CORDIS, BOSTON SCIENTIFIC, TERUMO, BIOTRONIK, PFIZER, ANGELINI, ASTRA ZENECA, TMC, IROKO. . ?. ST without DAPT.

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Doppia antiaggregazione dopo impianto di DES: prolungata... ma non troppo?

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  1. Doppia antiaggregazione dopo impianto di DES: prolungata... ma non troppo? UO Cardiologia ASL 9 Grosseto Ugo Limbruno Conflict of Interest: consulting for ABBOTT, CORDIS, BOSTON SCIENTIFIC, TERUMO, BIOTRONIK, PFIZER, ANGELINI, ASTRA ZENECA, TMC, IROKO.

  2. ? ST without DAPT bleeds with DAPT ? current practice risk • NEJM 2010;362:1374 • Heart 2009;95:1579 DAPT duration DAPT duration DAPT duration 1 mo 3 mo 6 mo 1 year time after DES

  3. 528 pts

  4. Unplanned DAPT withdrawal Intentional DAPT withdrawal ≠

  5. ≠ Unplanned DAPT withdrawal Intentional DAPT withdrawal 0.3%/year freedom from ST (%) 3-6%/year 0.3%/year Roy et al. Am J Cardiol 2009;103:801 Kimura et al. Circulation 2009;119:987 Mauri et al. N Engl J Med 2007;356:1020

  6. Reasons for premature DAPT discontinuation Bleeding Surgery Peptic ulcer 70%! Latib et al, Am J Cardiol 2008;102:1477–1481

  7. Reasons for premature DAPT discontinuation Bleeding Surgery Peptic ulcer 70%! Latib et al, Am J Cardiol 2008;102:1477–1481 Rossini et al, Am J Cardiol 2011;107:186–194

  8. ASA + Thieno withdrawal J-Cypher Registry (10.778 pts) Only Thieno withdrawal Kimura et al. Circulation 2009;119:987

  9. >3 month 161 pts with definite ST 10 days ASA+Thieno (simultaneous) ASA+Thieno (sequential) Thieno only Eisenberg, et al. Circulation 2009;119:1634

  10. Stent thrombosis prolonged DAPT unplanned DAPT withdrawal Bleed, Surgery, Ulcer ASA + Thieno withdrawal Transfusion, Cancer: “thrombophilic state”

  11. J-Cypher Registry(10.778 pts) 6-month landmark analysis Kimura et al. Circulation 2009;119:987

  12. ACS vs Non-ACS ! Kimura et al. Circulation 2009;119:987

  13. WHC Registry(2.889 pts) Roy et al. Am J Cardiol 2009;103:801

  14. 6816 pts Risk of ST at 4 years Clopidogrel treatment duration (days) Schulz et al. Eur Heart J 2009;30:2714

  15. Stent thrombosis (3021 pts) Bleeding 0.3%/year 2%/year Airoldi et al. Circulation 2007;116:145 Latib et al. Am J Cardiol 2008;102:1477

  16. Bleeding & Outcome Latib et al. Am J Cardiol 2008;102:1477

  17. EXCELLENT trial (1428 pts) ACC 2011

  18. 2013 pts

  19. 2013 pts

  20. 2010 guidelines ...tailored DAPT duration?

  21. DES type & stent thrombosis

  22. 9-month strut coverage after PPCI (46 pts) Fan et al. Am J Cardiol 2010;105:972

  23. p=NS OCTAMI trial(44 pts) OCT uncovered struts 6 month after PPCI % uncovered struts ZES BMS Guagliumi, Musumeci et al. JACC Cardiovasc Interv 2010;3:680

  24. SCAAR registry: stent thrombosis BMS old -DES new -DES

  25. DES for ISR (3-month OCT)

  26. DESERT trial Population Protocol End point 15 pts with ISR after BMS DES OCT: 6-month strut coverage 15 pts with de novo lesion

  27. Accelerated reendothelization with 2nd generation DES? ST without DAPT bleeds with DAPT risk current practice DAPT duration DAPT duration 1 mo 3 mo 6 mo 1 year time

  28. Major bleeding (%) Response variability to clopidogrel over-responders major bleedings Sibbing D et al, J Thromb Haemost 2010 Sibbing D et al, J Thromb Haemost 2010

  29. Over-responders • Haemorrhagic diatesis • Prasugrel, Ticagrelor? ST without DAPT bleeds with DAPT risk current practice DAPT duration DAPT duration 1 mo 3 mo 6 mo 1 year time

  30. Mortality & platelet reactivity after ACS cardiac mortality, % high 1789 pts p<0.002 residual platelet reactivity low Parodi et al, JAMA 2011; 306:1215-1223.

  31. Multiple stenting • Left main stenting • Thrombophillic state, • low-responders • Uncovered/malapposed • struts at OCT? ST without DAPT bleeds with DAPT risk current practice DAPT duration DAPT duration DAPT duration 1 mo 3 mo 6 mo 1 year time

  32. Mortality & platelet reactivity after ACS thienopyridine dose-adjustment P= NS cardiac mortality, % high cardiac mortality, % 1789 pts p<0.002 residual platelet reactivity low low high residual platelet reactivity Parodi et al, JAMA 2011; in press.

  33. Conclusioni Aderenza alla DAPT cruciale nei primi 30gg!

  34. Conclusioni Sospensione DAPT dopo 30 gg: - pianificata ≠ non pianificata - solo thieno ≠ ASA+thieno Dopo 6 mesi la sospensione isolata di clopidogrel non è correlata, né quantitativamente né temporalmente, alla ST. La durata ottimale della DAPT potrebbe variare in funzione del tipo di DES, fattori clinici, complessità anatomica della PCI.

  35. Conclusioni ...e la durata ottimale DAPT con Ticagrelor o Prasugrel?

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