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PRACTICAL RECOMMENDATIONS ON ANTI-THROMBOTIC TREATMENT IN PATIENTS TREATED WITH DRUG-ELUTING STENTS

PRACTICAL RECOMMENDATIONS ON ANTI-THROMBOTIC TREATMENT IN PATIENTS TREATED WITH DRUG-ELUTING STENTS. Giuseppe Biondi-Zoccai Ospedale S. Giovanni Battista “Molinette” Università di Torino.

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PRACTICAL RECOMMENDATIONS ON ANTI-THROMBOTIC TREATMENT IN PATIENTS TREATED WITH DRUG-ELUTING STENTS

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  1. PRACTICAL RECOMMENDATIONS ON ANTI-THROMBOTIC TREATMENT IN PATIENTS TREATED WITH DRUG-ELUTING STENTS Giuseppe Biondi-Zoccai Ospedale S. Giovanni Battista “Molinette” Università di Torino Convegno Regionale Piemonte e Valle d’Aosta “La morte improvvisa dal neonato all’adulto: un evento sempre inevitabile?” - Torino, 28-29 Settembre 2007 (h14.45-15.00)

  2. Learning objectives • Goals of antithrombotic treatment in patients undergoing drug-eluting stenting (DES) • Pathophysiologic and clinical data on thrombotic risk in patients with DES • Practical recommendations

  3. Learning objectives • Goals of antithrombotic treatment in patients undergoing drug-eluting stenting (DES) • Pathophysiologic and clinical data on thrombotic risk in patients with DES • Practical recommendations

  4. Learning objectives • Goals of antithrombotic treatment in patients undergoing drug-eluting stenting (DES) • Clinical data on thrombotic risk in patients with DES • Practical recommendations

  5. Benefits of prolonged dual antiplatelet treatement 1501 patients treated with DES:no data on stent thrombosis (ST) Eisenstein et al, JAMA 2006

  6. Incidence and predictors of stent thrombosis in DES 2229 patients treated with DES:0.6% subacute ST; 0.7% late ST; 1.3% total ST at 9 months !!! !!! !!! Iakovou et al, JAMA 2006

  7. Is dual antiplatelet therapy truly beneficial beyond 6 months? 3021 patients treated with DES:1.4% ST <6 months; 0.5% ST 6-18 months ; 1.9% total ST at 18 months Airoldi et al, Circulation 2007

  8. Learning objectives • Goals of antithrombotic treatment in patients undergoing drug-eluting stenting (DES) • Pathophysiologic and clinical data on thrombotic risk in patients with DES • Practical recommendations

  9. Resources for practical recommendations • Grines CL, Bonow RO, Casey DE Jr, et al; American Heart Association; American College of Cardiology; Society for Cardiovascular Angiography and Interventions; American College of Surgeons; American Dental Association; American College of Physicians. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation. 2007 Feb 13;115(6):813-8. • Hodgson JM, Stone GW, Lincoff AM, et al; Society for Cardiovascular Angiography and Interventions. Late stent thrombosis: considerations and practical advice for the use of drug-eluting stents: a report from the Society for Cardiovascular Angiography and Interventions Drug-eluting Stent Task Force. Catheter Cardiovasc Interv. 2007 Feb 15;69(3):327-33. • Silber S, Albertsson P, Aviles FF, et al; Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J. 2005 Apr;26(8):804-47. • Steinhubl SR, Berger PB, Mann JT 3rd, et al; CREDO Investigators. Clopidogrel for the Reduction of Events During Observation. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA. 2002 Nov 20;288(19):2411-20.

  10. Resources for practical recommendations • Grines CL, Bonow RO, Casey DE Jr, et al; American Heart Association; American College of Cardiology; Society for Cardiovascular Angiography and Interventions; American College of Surgeons; American Dental Association; American College of Physicians. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation. 2007 Feb 13;115(6):813-8. • Hodgson JM, Stone GW, Lincoff AM, et al; Society for Cardiovascular Angiography and Interventions. Late stent thrombosis: considerations and practical advice for the use of drug-eluting stents: a report from the Society for Cardiovascular Angiography and Interventions Drug-eluting Stent Task Force. Catheter Cardiovasc Interv. 2007 Feb 15;69(3):327-33. • Silber S, Albertsson P, Aviles FF, et al; Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J. 2005 Apr;26(8):804-47. • Steinhubl SR, Berger PB, Mann JT 3rd, et al; CREDO Investigators. Clopidogrel for the Reduction of Events During Observation. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA. 2002 Nov 20;288(19):2411-20. 12m of ASA+TNP 12m of ASA+TNP 6-12m of ASA+TNP 12m of ASA+TNP ASA=aspirin; TNP=thienopyridine (clopidogrel or ticlopidine)

  11. 66-y-o woman with effort angina PTCA with non-overlapping bare-metal stents in right coronary artery

  12. Optimal antithrombotic Rx? TNP=thienopyridine (clopidogrel or ticlopidine)

  13. Optimal antithrombotic Rx? TNP=thienopyridine (clopidogrel or ticlopidine)

  14. 58-y-o man with silent ischemia PTCA with multiple small diameter paclitaxel-eluting stents in distal right coronary branches

  15. Optimal antithrombotic Rx? TNP=thienopyridine (clopidogrel or ticlopidine)

  16. Optimal antithrombotic Rx? TNP=thienopyridine (clopidogrel or ticlopidine)

  17. 71-y-o woman with unstable angina PTCA with sirolimus-eluting stents in unprotected distal left main and proximal left anterior descending

  18. Optimal antithrombotic Rx? TNP=thienopyridine (clopidogrel or ticlopidine)

  19. Optimal antithrombotic Rx? TNP=thienopyridine (clopidogrel or ticlopidine)

  20. 56-y-o man with de novo ST-elevation myocardial infarction PTCA with bare-metal stent in mid left anterior descending

  21. Optimal antithrombotic Rx? TNP=thienopyridine (clopidogrel or ticlopidine)

  22. Optimal antithrombotic Rx? TNP=thienopyridine (clopidogrel or ticlopidine)

  23. Take home messages

  24. 1. Not all patients are born equal

  25. 2. Both accurate choice of revascularization strategy (CABG, PCI with BMS, PCI with DES, or none) AND aggressive medical RX are pivotal

  26. 3. Avoid aggressive and long-term dual antiplatelet therapy for all patients, as every single one should be handled differently All from All different

  27. More humbly… BMS=bare-metal stent; CSA=chronic stable angina; DES=drug-eluting stent; NSTEACS=non-ST-elevation acute coronary syndromes; PCI=percutaneous coronary intervention; POBA=pure-only balloon angioplasty; STEMI=ST-elevation myocardial infarction; TNP=thienopyridine (clopidogrel or ticlopidine)

  28. For further slides on these topics please feel free to visit the metcardio.org website:http://www.metcardio.org/slides.html

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