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TERAPIAANTITROMBOTICANELLASCAINPAZIENTICONFACRONICA
Dr.ssaPatriziaNoussanOspedaleSanGiovanniBosco
Torino
CardioAlessandria12-13giugno2015
FApermanenteeSCAunaassociazionepericolosa…..
• PrevalenzadiFA1-2%• L’80%deipazien;inFAhaindicazioneaOAC• Il30%deipazien;inFAhaunaconcomitantepatologiavascolareenel20%andràincontroaPTCAconimpiantodistent
InEuropa1-2milionidipazienKinOACpotrebberoavereindicazioneaunaPTCAconstenKng
ReccomendaKonforanKthromboKctherapyinACS-NSTEeSTEMIpaKentsundergoingPCI
Primaryendpoint:firstoccurrenceofstroke,non-CNSsystemicembolus,AMIovasculardeath
(JAmCollCardiol2008;51:818–25)
Kaplan-MeierSurvivalCurvesinRelaKontoAnKcoagulaKonUseatDischarge
RiskofBleedingWithSingle,Dual,orTripleTherapyWithWarfarin,Aspirin,andClopidogrelinPaKentsWithAtrialFibrillaKon
Arch Intern Med. 2010;170(16):1433-1441. !
TRIPLETHERAPY(TT)ASA+P2Y12I+OAC(VKA/NOACS)
4-16%rischiodisanguinamen;
BleedingcomplicaKons ThromboKccomplicaKonsStroke–stentthrombosis
DUALTHERAPYOAC+SINGLEANTIPLATELET
50%isanguinamenK
2010
StudyDesign1:1Randomisa5on:Doubletherapygroup:OAC+75mgClopidogrelqd1monthminimumaSerBMS1yearaSerDES
TripletherapygroupOAC+75mgClopidogrelqd+80mgAspirinqd1monthminimumaSerBMS1yearaSerDES
Followup:1yearPrimaryEndpoint:Theoccurenceofallbleedingevents(TIMIcriteria)SecondaryEndpoints:- CombinaKonofstroke,death,myocardialinfarcKon,stentthrombosisandtargetvesselrevascularisaKon-Allindividualcomponentsofprimaryandsecondaryendpoints
TheWOESTTrial:FirstrandomisedtrialcomparingtworegimenswithandwithoutaspirininpaKentsonoralanKcoagulanttherapy
undergoingcoronarystenKng
|
PrimaryEndpoint:TotalnumberofTIMIbleedingevents
Days
Cumula;
veincide
nceofbleed
ing
0 30 60 90 120 180 270 365
0%
10%
20%
30%
40%
50%
284 210 194 186 181 173 159 140natrisk:279 253 244 241 241 236 226 208
TripletherapygroupDoubletherapygroup 44.9%
19.5%
p<0.001HR=0.3695%CI[0.26-0.50]
PrimaryEndpoint:BleedingeventsTIMIclassifica;on
05
101520253035404550
TIMIMinimal
TIMI Minor TIMI Major Any TIMIbleeding
Doubletherapygroup
Tripletherapygroup
6.5
16.7
11.2
27.2
3.35.8
19.5
44.9%
p<0.001
p<0.001
p<0.001
p=0.159
WOEST
|
Conclusions1. FirstrandomizedtrialtoaddresstheopKmalanKplatelettherapyinpaKentsonOAC
undergoingcoronarystenKng
2. Inthisstudywhichwasspecificallydesignedtodetectbleedingevents,thebleedingratewashigherthanexpected
3. Primaryendpointwasmet:OACplusclopidogrelcauseslessbleedingthantripleanKthromboKctherapy,butnowshowninarandomizedway
4. Secondaryendpointwasmet:withdoubletherapythereisnoexcessofthromboKc/thromboembolicevents:stroke,stentthrombosis,targetvesselrevascularisaKon,myocardialinfarcKonordeath
5. Lessall-causemortalitywithdoubletherapy
LimiK:Numerositàdelcampione(576pts)-69%deipazienKerainOACperFA–accesso
femoralenel74%-PCIelejvanel70-75%-usononrouKnariodiPPI-TTper12mesi
JACCVol.62,2013;62:981–989
InreallifeAFpaKentswithindicaKonsformulKpleanKthromboKcdrugsakerMI/PCI,OACandclopidogrelwasequalorbemeronbothbenefitandsafeyoutcomes
comparedtotripletherapy
STEMIpaKents
ACS-NSTEpaKents
Ø PrincipalsaspectsoftheESCguidelinesareconsideredintherespondingcentresØ UncertaintyintheissueofopKmalcomposiKonandduraKonofmulKpleanKthromboKctreatmentandtheopKmalregimen(s)ofNOACSintreatmentstrategies
2014
ToevaluatewethershorteningtheduraKonofclopidogreltherapyfrom6monthsto6weeksakerDESimplantaKonwasassociatedwithasuperiornetclinicaloutcomeinpaKentsreceivingconcomitantaspirinandOAC
ThestudywilltestthehypotesisthatDAPTcomparedwithTTwithnonvalvularAFatlowtomoderateriskofstrokeCHADS2<2akerPCISreducestheriskofbleedingandisnotinferiortoTTforprevenKngthromboemboliccomplicaKons
PrimaryEndpoint:acompositeofDeath,MI,defST,strokeorTIMImajorbleedingat9months
NOACs• IlruolodeiNOACsneipazien;conFAeACSnonè
statovalutatodireeamentemaderivasopraeueodaanalisipost-hocodaRCTssull’u;lizzodeiNOACsinassociazioneallaterapiaan;aggreganteneipazien;ACS-PCI
• Quandosiu;lizzaunNOACinassociazioneaclopidogrelobassadosediASA,ladosediNOACdau;lizzareèlapiùbassatestataneglistudidiprevenzionedellostrokenellaFA
• Unarecentemetanalisinonhaevidenziatodifferenzenell’incidenzadiIMAtraNOACseWarfarin
• NOACstrialincorso:PIONEERAF-PCIRE-DUALPCI
Conclusions:RatesofthromboKcandbleedingeventsweresimilarinpaKentswithTTandpaKentswithTicagrelorandwarfarin
ConsensusrecommendaKon• Nei pazien; con FA non valvolare u;lizzare gli score di rischio
CHA2DS2-VASC eHas-BLED eGRACERisk per la stra;ficazione delrischioACS
• Se OAC è VKA à TTR>70% con INR 2-2.5 se in associazione aclopidogrele/oASA(75-100mg)(IIa,C)
• SE OAC è NOAC , deve essere u;lizzata la posologia più bassadisponibile ma risultata efficace nella prevenzione dello strokeàDabigatran 110 b.i.d Rivaroxaban 15mg o.d. Apixaban 2.5mg b.i.d.(IIb,C)
• Neipazien;conFAnonvalvolareecoronaropa;astabile>12mesimantenere VKA o NOAC (IIa, B). In casi seleziona;(PTCA di Tc, IVAprossimale , biforcazioni, IMA ricorren; ) si può considerare unprolungamentodelladupliceterapia(IIb,B)
• Accessoradiale,“newgenera;on“DESvsBMS• NOPrasugreleTicagrelornellaTT(III,C)
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