Go, A. S. et al. JAMA 2001;285: La combinazione antitrombotica appropriata nel paziente con fibrillazione atriale e indicazione alla TAO sottoposto ad angioplastica coronarica con impianto di stent ANDREA RUBBOLI Unità Operativa di Cardiologia Laboratorio di Cardiologia Interventistica Ospedale Maggiore Bologna

Go, A. S. et al. JAMA 2001;285: DISCLOSURES Lecture honoraria and/or research grant and/or consulting: Astra Zeneca Bayer Healthcare Boehringer Ingelheim Daiichi Sankyo Pfizer-BMS

Go, A. S. et al. JAMA 2001;285: OAC vs. DAPT Stroke Subacute stent thrombosis The ACTIVE Investigators. Lancet 2006;367: Bertrand ME et al. Circulation 1998;98:

Go, A. S. et al. JAMA 2001;285: QUESTIONS 1.OAC + 1 or 2 antiplatelets? 2. clopidogrel or prasugrel/ticagrelor? 3.warfarin or NOAC?

Go, A. S. et al. JAMA 2001;285: RECOMMENDATIONS: 1. Triple therapy of OAC, aspirin, and clopidogrel (Class IIa; LOE C) RECOMMENDATIONS: 1. Triple therapy of OAC, aspirin, and clopidogrel (Class IIa; LOE C) Lip GY et al. Eur Heart J 2014;35:

Go, A. S. et al. JAMA 2001;285: Safety and efficacy of triple antithrombotic therapy after percutaneous coronary intervention in patients needing long-term anticoagulation Singh PP et al. Ther Adv Cardiovasc Dis 2011;5:23-31 Vitamin K-antagonists

Go, A. S. et al. JAMA 2001;285: Bleeding avoiding strategies 1reduced intensity of OAC (i.e., target INR ) 2. reduced duration of triple therapy (i.e., 1 to 3-6 months) 3.routine use of gastric protection (i.e., PPIs)

Go, A. S. et al. JAMA 2001;285: Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial Dewilde WJ et al. Lancet 2013;381: ° endpoint – Safety (total bleeding) 1° endpoint – Safety (total bleeding) 2° endpoint - Efficacy (stroke, death, MI, re-PCI/CABG, stent thrombosis) 2° endpoint - Efficacy (stroke, death, MI, re-PCI/CABG, stent thrombosis)

Go, A. S. et al. JAMA 2001;285: Rubboli A, Limbruno U. G Ital Cardiol 2013;14:564-8 Sicurezza differenza trascinata da emorragie clinicamente non maggiori eccesso di emorragie vs. Letteratura/pianificazione dello studio Efficacia differenza trascinata da mortalità non-cardiaca sottodimensionamento per identificare differenze di trombosi di stent incertezza nei pazienti con “resistenza” al clopidogrel

Go, A. S. et al. JAMA 2001;285: RECOMMENDATIONS: 1. Triple therapy of OAC, aspirin, and clopidogrel (Class IIa; LOE C) 2. Dual therapy of OAC, and clopidogrel (Class IIb; LOE C)† † selected pts. at high bleeding risk and low risk of stent thrombosis/recurrent ischemic events RECOMMENDATIONS: 1. Triple therapy of OAC, aspirin, and clopidogrel (Class IIa; LOE C) 2. Dual therapy of OAC, and clopidogrel (Class IIb; LOE C)† † selected pts. at high bleeding risk and low risk of stent thrombosis/recurrent ischemic events Lip GY et al. Eur Heart J 2014;35:

Go, A. S. et al. JAMA 2001;285: Sarafoff N et al. J Am Coll Cardiol 2013;61: HR 1.4 (95% CI ; p= 0.61) HR 4.6 (95% CI ; p<0.001) Triple therapy of VKA + aspirin + clopidogrel/prasugrel after PCI

Go, A. S. et al. JAMA 2001;285: NOACs in AF + PCI Gibson CM et al. Am Heart J 2015;169: Accessed August 14, 2014 PIONEER-AF PCIRE-DUAL PCI Rivaroxaban 15mg OD + clopidogrel/ticagrelor/prasugrel Dabigatran 110 mg BID + clopidogrel/ticagrelor vs Rivaroxaban 2.5mg BID + clopidogrel/ticagrelor/prasugrel + ASA Dabigatran 150mg BID + clopidogrel/ticagrelor vs Warfarin (INR ) + clopidogrel/prasugrel/ticagrelor + ASA Warfarin (INR ) + clopidogrel/ticagrelor + ASA

Go, A. S. et al. JAMA 2001;285: Dans AL et al. Circulation 2013;127: RR of major bleed vs OAC alone: OAC* + SAPT: 1.6 OAC* + DAPT: 2.3 * irrespective of the oral anticoagulant (warfarin, dabigatran 110 or dabigatran 150) RR of major bleed vs OAC alone: OAC* + SAPT: 1.6 OAC* + DAPT: 2.3 * irrespective of the oral anticoagulant (warfarin, dabigatran 110 or dabigatran 150) Concomitant Use of Antiplatelet Therapy with Dabigatran or Warfarin in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY®) Trial Dans AL et al. Circulation 2013;127:634-40

Go, A. S. et al. JAMA 2001;285: Viewpoint: a proposal for a simple algorithm for managing oral anticoagulation and antiplatelet therapy in patients with non-valvular atrial fibrillation and coronary stents Steg PG, Bhatt DL. Eur Heart J Acute Cardiovasc Care 2015; epub ahead of print

Go, A. S. et al. JAMA 2001;285: CONCLUSIONI Nel paziente in TAO sottoposto a PCI con stent: 1.la combinazione antitrombotica (iniziale) appropriata è generalmente TT* 2.la DT** può essere considerata in casi selezionati 3.vanno sempre implementate misure per ridurre l’aumentato rischio emorragico 4.i nuovi anticoagulanti orali potrebbero rappresentare la TAO da preferire * OAC (con anticoagulante in corso) + aspirina + clopidogrel; ** OAC (con anticoagulante in corso) + clopidogrel