Go, A. S. et al. JAMA 2001;285:2370-2375. La combinazione antitrombotica appropriata nel paziente con fibrillazione atriale e indicazione alla TAO sottoposto.

Presentazione sul tema: "Go, A. S. et al. JAMA 2001;285:2370-2375. La combinazione antitrombotica appropriata nel paziente con fibrillazione atriale e indicazione alla TAO sottoposto."— Transcript della presentazione:

1 Go, A. S. et al. JAMA 2001;285:2370-2375. 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

2 Go, A. S. et al. JAMA 2001;285:2370-2375. DISCLOSURES Lecture honoraria and/or research grant and/or consulting: Astra Zeneca Bayer Healthcare Boehringer Ingelheim Daiichi Sankyo Pfizer-BMS

3 Go, A. S. et al. JAMA 2001;285:2370-2375. OAC vs. DAPT Stroke Subacute stent thrombosis The ACTIVE Investigators. Lancet 2006;367:1903-12 Bertrand ME et al. Circulation 1998;98:1597-1603

4 Go, A. S. et al. JAMA 2001;285:2370-2375. QUESTIONS 1.OAC + 1 or 2 antiplatelets? 2. clopidogrel or prasugrel/ticagrelor? 3.warfarin or NOAC?

5 Go, A. S. et al. JAMA 2001;285:2370-2375. 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;35:3155-79

6 Go, A. S. et al. JAMA 2001;285:2370-2375. 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

7 Go, A. S. et al. JAMA 2001;285:2370-2375. Bleeding avoiding strategies 1reduced intensity of OAC (i.e., target INR 2.0-2.5) 2. reduced duration of triple therapy (i.e., 1 to 3-6 months) 3.routine use of gastric protection (i.e., PPIs)

8 Go, A. S. et al. JAMA 2001;285:2370-2375. 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;381:1107-15 1° 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)

9 Go, A. S. et al. JAMA 2001;285:2370-2375. 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

10 Go, A. S. et al. JAMA 2001;285:2370-2375. 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;35:3155-79

11 Go, A. S. et al. JAMA 2001;285:2370-2375. Sarafoff N et al. J Am Coll Cardiol 2013;61:2060-6 HR 1.4 (95% CI 0.3-6.1; p= 0.61) HR 4.6 (95% CI 1.9-11.4; p<0.001) Triple therapy of VKA + aspirin + clopidogrel/prasugrel after PCI

12 Go, A. S. et al. JAMA 2001;285:2370-2375. NOACs in AF + PCI Gibson CM et al. Am Heart J 2015;169:472-8 www.http//clinicaltrials.gov/ct2/show. 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 2.0-3.0) + clopidogrel/prasugrel/ticagrelor + ASA Warfarin (INR 2.0-2.5) + clopidogrel/ticagrelor + ASA

13 Go, A. S. et al. JAMA 2001;285:2370-2375. Dans AL et al. Circulation 2013;127:634-40 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

14 Go, A. S. et al. JAMA 2001;285:2370-2375. 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

15 Go, A. S. et al. JAMA 2001;285:2370-2375. 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