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Antiplatelet Therapy in Renal Dysfunction

Antiplatelet Therapy in Renal Dysfunction. Moderator E. Magnus Ohman, MD Professor of Medicine Director Program for Advanced Coronary Disease Duke University Medical Center Durham, North Carolina. Panelists Robert F. Storey, MD

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Antiplatelet Therapy in Renal Dysfunction

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  1. Antiplatelet Therapy in Renal Dysfunction Moderator E. Magnus Ohman, MD Professor of Medicine Director Program for Advanced Coronary Disease Duke University Medical Center Durham, North Carolina Panelists Robert F. Storey, MD Reader and Honorary Consultant in Cardiology Department of Cardiovascular ScienceUniversity of SheffieldSheffield, United Kingdom Stephen D. Wiviott, MD Assistant Professor of MedicineTIMI Study GroupCardiovascular DivisionBrigham and Women's HospitalHarvard Medical School Boston, Massachusetts

  2. GFR Calculator IDMS = isotope dilution mass spectrometry; KDOQI = Kidney Disease Outcomes Quality Initiative; http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm

  3. Stages of CKD Kidney Disease Improving Global Outcomes initiative recommends adding "T" to transplant recipients at any stage and "D" for stage 5 treated by dialysis http://www.kidney.org/professionals/KLS/aboutCKD.cfm

  4. European Society of Cardiology UA/NSTEMI Guidelines 2007 Class I: CrCl and/or GFR should be calculated for every patient hospitalized for NSTE-ACS (LoE B) MDRD*: eGFR = 186 x (SCr)-1.154 x (age) -0.203: x (0.742 if female) x (1.210 if African American) • *Not validated in: • Age < 18 years or > 70 years • Pregnant women • Racial/ethnic groups other than Caucasian and African American • Individuals with normal kidney function Bassand JP, et al. Eur Heart J.2007;28:1598-1660. http://www.kidney.org/professionals/KLS/aboutCKD.cfm

  5. REACH: MACE by Creatinine Clearance P for trend < .01 P for trend < .01 Patients (%) P for trend < .01 Increased risk for significant bleeding with severe CKD Adj OR, 1.60 (1.01-2.54; P < .001) Reprinted from Dumaine RL, et al. Am Heart J.2009;158:141-148.e1, with permission from Elsevier.

  6. ACTION: CKD in STEMI and NSTEMI STEMI No CKD (N = 13,221) 69.5% CKD (N = 5808) 30.5% NSTEMI No CKD (N = 17,393) 57.1% CKD (N = 13,609) 42.9% NSTEMI STEMI Fox CS, et al. Circulation.2010;121:357-365.

  7. ACTION: In-Hospital Mortality by CKD Stage P < .0001 P < .0001 In-HospitalDeath (%) Pinteraction < .0001 From Fox CS, et al. Circulation.2010;121:357-365. Republished with permission.

  8. ACTION: Non-CABG Major Bleeding Rates by CKD P < .0001 P < .0001 Non-CABG Major Bleed ( %) N = 5808 STEMI patients with CKD and N = 13,069 NSTEMI patients with CKD Fox CS, et al. Circulation.2010;121:357-365.

  9. ACTION: Acute Kidney Injury and In-Hospital Mortality P < .0001 P < .0001 In-HospitalDeath (%) • ∆ Admission and peak SCr • No AKI : < 0.3 mg/dL • Mild AKI: 0.3 - < 0.5 mg/dL • Moderate AKI: 0.5- < 1.0 mg/dL • Severe AKI: ≥ 1.0 mg/dL AKI = acute kidney injury; SCr = serum creatinine Fox CS, et al. American Heart Association 2010. Abstract 12592.

  10. O CH3 O C N S Cl Hydrolysis (Esterases) hCE1 85% Inactive Metabolites Clopidogrel → Active Metabolite Prodrug Intestinal Absorption Clopidogrel CYPs: 1A2 2B6 2C19 O CH3 O C Hepatic Oxidation (Cytochrome P450) 2-step CYPs: 3A 2B6 2C9 2C19 N O S Cl OCH3 Active Metabolite O N HOOC Cl * HS Kurihara A, et al.Drug Metab Rev. 2005;37:99. Tang M, et al. J Pharmacol Exp Ther. 2006;319:1467-1476.

  11. Reduced Antiplatelet Response in CKD N = 306 patients with type 2 diabetes mellitus Reprinted from Angiolillo DJ, et al. J Am Coll Cardiol.2010;55:1139-1146, with permission from Elsevier.

  12. Clopidogrel Less Effective in Renal Dysfunction *Significant RRR or significant interaction between subgroups From Montalescot G, et al. Circulation.2010;122:1049-1052.Republished with permission.

  13. Prasugrel and Ticagrelor Not Affected *Significant RRR or significant interaction between subgroups From Montalescot G, et al. Circulation.2010;122:1049-1052.Republished with permission.

  14. PLATO: Non-CABG TIMI Major Bleeding by CKD Status No CKD PLATO N = 15,202 ACS patients(3237 with CKD) CKD TIMI Major Bleeding (%) Clopidogrel = 300- to 600-mg loading dose (LD), 75-mg maintenance dose Ticagrelor = 180-mg LD, 90 mg twice daily Ticagrelor is an investigational agent James S, et al. Circulation.2010;122:1056-1067.

  15. Antithrombotic Drug Use in CKD* *Corrected text (erratum in original epub). www.escardio.org/guidelinesWijns W, et al. Eur Heart J.2010;31:2501-2555.

  16. ACTION: Excess* Antithrombin Dosing by CKD P = .45 P < .0003 Antithrombin Excess Dosing ( %) N = 5808 STEMI patients with CKD and N = 13,069 NSTEMI patients with CKD *Above guideline recommendations for UFH, LMWH , and /or lytics. Fox CS, et al. Circulation.2010;121:357-365.

  17. Fondaparinux Enoxaparin OASIS 5: Bleeding by Creatinine Clearance P = .001 P < .001 Major Bleeding (%) CrCl < 30 mL/min CrCl ≥ 30 mL/min Fondaparinux 2.5 mg daily Enoxaparin 1 mg/kg twice daily OASIS 5 Investigators. N Engl J Med.2006;354:1464-1476.

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