antitrombotik,ppt7.pptx

8/10/2019 antitrombotik,ppt7.pptx

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ANTITHROMBOTIC THERAPY IN ACUTE CORONARY

SYNDROME

BY:

Topan Binawan

Supervisor :

Prof.DR.dr.Moch.Fathoni,SpJP(K),FIHA,FAsCC,FAPSC

CARDIOLOGY PAPERS

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introduction

Coronary heart disease : a disability premature deathsworldwide

Each year : 1,300,000 non-Qmyocardial infarction,350,000 Q wave myocardial infarction

in the US

Antithrombotic proper handling during myocardial ischemiaacute, cardiac care to help provide safe and effective


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Impact of bleeding ACSpatient outcomesPCIhighlight the importance of

antithrombotic doses,especially vulnerable

populations such as womenand the elderly

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Acute Coronary Syndrome (ACS)

Manifestation of spectrum acute and hard is an

emergency condition of coronary because of

imbalance oxygen myocard need & blood

flow.

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Classification

Based on ECG andcardiac enzymes,ACS is classified

into:

STEMI: STelevation, elevatedcardiac enzymes

NSTEMI: STdepression, T-wave

inversion, elevatedcardiac enzymes

Unstable Angina:Non specific EKG

changes, normalcardiac enzymes

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Pathogenesis

UnstableAngina

Plaque Rupture

Thrombosis &

platelet aggregation

Vasospasme

Plaque erotionwithout rupture.

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STEMIInfark : plaque becomefissure and rupture,

thrombogenesismuralthrombus on location ofruptureocclution of

coronary artery.

Location of plaquerupture, agonis

activation of plateletstromboxan A2the

receptor glycoprotein IIb/ IIIa.

The receptor has a highaffinity amino acid

sequence : bind to twodifferent platelets,

platelet aggregation

Tissue factorCoagulation cascade

endothelial cells :damaged.

Activated fo VII and X,conversion of

prothrombin -thrombin,then converts

fibrinogen- fibrin.

Undergo coronaryartery occlusionby a

thrombus composed ofplatelets and fibrin

aggregates

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NSTEMI

Acute thrombosis occurs NSTEMI / processescoronary vasoconstriction.

Acute thrombosis in coronary artery plaquerupture begins with an unstable

This unstable plaque has a large lipid core, alow density of smooth muscle, thin fibrous cap

and a high concentration of tissue factor.

Location of plaque rupture in macrophage and

lymphocyte cell encounteredinflammation ;TNF , and IL-6.

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Therapy antithrombotic in ACS

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Non Stable Angina/NSTEMI

The intensity of medical therapy based risk

doctor assessment ischemia and bleeding

events.

This factor combined approach physicians to

the most appropriate strategy risk assessment

early invasive versus early conservative.

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TIMI : Trombolysis risk score in Myocardial

Infarction, GRACE : risk score Global Registry of Acute

Coronary Events, and risk models Platelet

glycoprotein IIb / IIIa in Unstable angina

PURSUIT : Receptor Suppression Using Integrilin

Therapy.

To help formulate management better strategies


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High risk scoreearly invasive.

Low risk scoreinitial conservative.

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Antiplatelet Strategy on unstable angina / NSTEMI

ACC / AHA, ESC, and ACCP : the highest

aspirin immediately on non-stable angina /

NSTEMI. Start ; > 160 mg, the long-termmaintenance : aspirin


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Antiplatelet Strategy on unstable angina / NSTEMI

Guidelines ACC / AHA and ACCP

recommends Class I / class 1A, consecutive

use of aspirin and clopidogrel, whilelowering the therapeutic use of GP IIb / IIIa

inhibitors (ACC / AHA Class IIb, LOE; B;

ACCP class 2B) : initial conservative

strategy.

The option to use a replacement bivalirudinGP IIb / IIIa inhibitor-treated patients with

invasive : thiopyridine early (


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Selection of Anticoagulants: early conservative

strategies in unstable angina / NSTEMI

Guidelines ACC / AHA recommendationof UFH or enoxaparin (Class I, LOE: A)or fondaparinux (Class I, LOE: B) withenoxaparin / fondaparinux are preferred(Class IIa, LOE: B).

Similarly, the ESC guidelinesrecommendation fondaparinux (Class 1,LOE: A) or UFH (Class 1, LOE C) in aconservative, but also loweredrecommendation for enoxaparin (ClassIIa, LOE: B)

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The Fifth Organization to Assess Strategies in

Acute Ischemic Syndromes (OASIS-5)

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Guideline recommendations and level of evidence

for anticoagulation in non-ST elevation ACS

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Selection of anticoagulants: an early invasive strategy in

unstable angina / NSTEMI

Anticoagulants are one of the 4 currently available > than norecommended for the treatment of non-ST elevation ACS : (ACC / AHAClass I, LOE: A], ESC [Class I, LOE: A], and ACCP [Class 1A]).

Invasive strategy guidelines : the ACC / AHA recommendation UFH orenoxaparin (Class I, LOE: A) or bivalirudin or fondaparinux (Class I,

LOE: B).

ESCurgent invasive UFH (Class I, LOE: C), enoxaparin (Class IIa,LOE: B), bivalirudin (Class I, LOE: B) recommendation.

ESC : urgent invasive no recommendation Fondaparinux

Early invasive strategy ACCP recommendations UFH with GP IIb /

IIIa inhibitor IV use in than LMWH (enoxaparin) or fondaparinux (Class1B). 19


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Superior Yield of the New Strategy of Enoxaparin,

Revascularization and Glycoprotein IIb/IIIa inhibitors

(SYNERGY)

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Guideline recommendations and level of evidence for

anticoagulation in non-ST elevation ACS

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Antiplatelet drugs in patients with STEMI

All the guidelines, a starting dose of nonenteric-aspirin 150-325 mg, daily dose > lowthereafter ( Low high risk for bleeding(Class IIa, LOE: C).

STEMI post-PCI recommendations for 1 yearclopidrogel after drug elution stents and 1month to 1 year bare metal stents (Class I,LOE: B)

ACC / AHA STEMIsupport the addition ofclopidogrel + aspirin STEMI (initiation ofclopidogrel 300 mg


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The selection of anti thrombotic patients with a fibrinolysis

ACC / AHA recommendations fibrinolysisanticoagulant treated patients at least 48 hours

(Class I, LOE: C), continued up to 8 days or untilthe patients home (Class I, LOE: A).

UFH (Class I, LOE: C) enoxaparin (Class I, LOE:A), / fondaparinux (Class I, LOE: B)

recommendation on fibrinolysis

ACCP recommendations antithrombin therapy than

no antithrombin therapy (Class 1A).Regarding the use of LMWH, ACCP >

recommendation reviparin than no treatment(Class 1B).

ESC for co-STEMI anticoagulant therapy inpatients with fibrinolysis (non-streptokinase)

include enoxaparin and UFH (Class I, LOE: A).Patients with streptokinase, fondaparinux or

enoxaparin (Class IIa, LOE: B) or UFH (Class IIa,LOE: C) recommendation.

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R d ti f ti l ti STEMI


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Recommendations for anticoagulation on STEMI

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The selection of the antithrombotic primary PCI

ACC / AHA supports thecontinuation of anticoagulants onthe scope of peri-PCI (Class I)

primary PCI of STEMI.Recommendations include UFH

(Class I, LOE: C) with the option ofswitching to bivalirudin (Class I,LOE: C) for the previous UFH.Enoxaparin (Class I, LOE: B) /

fondaparinux (Class I, LOE: C) isreceived anticoagulant STEMI with

PCI

ACCP and strong ESCrecommendation fondaparinux on

primary PCI.

ACCP supports the use of UFH

dosing based on the weight(Class1B) and abciximab (inhibitor of GPIIb / IIIa) IV during primary PCI

(Class 1B) for STEMI.ESC Guidelines recommendationUFH (Class I, LOE: C) / bivalirudin

(Class IIa, LOE: B)

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T iti t P t ACS A ti Th b ti Th f


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Transition to Post-ACS Anti Thrombotic Therapy ofChronic

The guidelines continue to support

low-dose aspirin, ideally 100 mg /day.

Patients in-stent acute coronarysyndrome, the dose of aspirin (162-

325 mg) can be used for the firstmonth of bare metal stents, and for

3-6 months of drug-eluting stents.

Clopidogrel is recommended at least

one month at a bare metal stent andideally for at least 1 year drug-elutingstents.

Oral anticoagulants + dualantiplatelet no recommendation for

secondary prevention in the absence

of a clear indication (ie AF, DVT).

Warfarin may be considered inpatients with a high risk of ischemia

and bleeding risk is low if notintolerant of clopidogrel (Class IIb,

LOE: B).

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RESUME

Using anti-platelet therapy and anti-coagulants on

ACS clinical outcomes associated development ofshort-term and long-term, depending onconservative treatment or acute coronaryrevascularization.

Selecting anti-thrombotic therapy lowers the riskof ischemic while minimizing the risk of bleedingfrom various subtype ACS.

Selecting of appropriate antithrombotic during the

transition from the phase of the sub-acute andchronic secondary prevention can be worthattention

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Thank you

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Karakteristik pasien strategi invasif awal pedoman

ACC/AHA dan ESC.

Pedoman ACC/AHA dan ESC

Angina menetap /kambuhan meskipun ada

terapi medis intensif, tanpa menghiraukan

perubahan gelombang ST atau T

Troponin meningkat

Perubahan gelombang ST atau T dinamis,

tanpa menghiraukan gejalanya.

Fraksi ejeksi < 40%

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Tanda-tanda atau gejala kegagalan jantung /

regurgitasi mitral baru

Ketidakstabilan hemodinamik

VT atau VF berkelanjutan

PCI dalam 6 bulan

CABG sebelumnya

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Pedoman ACC/AHA

Temuan beresiko tinggi pengujian non-invasif Skor resiko iskemia tinggi

Pedoman ESC

DM

Disfungsi ginjal (eGFR < 60 ml/menit/1,73

m2)

MI sebelumnya

Skor resiko GRACE menengah hingga tinggi

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