|  | | Dia 2 |
|
 | | Mortality in hospital and at 6 months in low, intermediate and high risk categories in registry populations according to the GRACE Risk score http://www.outcomes.org/grace |
|  | | Question: Strategy ? |
|
 | | Relative risk of all cause of mortality |
|  | | Management Strategy |
|
 | | Time to catheterization (hrs) |
|  | | Dia 8 |
|
 | | A.S.A.P < 24 h vs delayed > 36h - ACS met 2/3 > 60 y, pos marker (76%), ischemic ECG (80%) and revasc possible |
|  | | No early hazard! |
|
 | | GRACE > 141 14% 21% p=0.009 Major bleeds 3.1 3.5% p=0.53 |
|  | | Early (≤24 h, median=14h) or delayed intervention ( ≥36 h, median=50h) N=3000 |
|
 | | Early (≤24 h, median=14h) or delayed intervention ( ≥36 h, median=50h) |
|  | | Why not immediately “STEMI-like”? |
|
 | | ABOARD study design |
|  | | Index ACS event |
|
 | | In-hospital medications |
|  | | Time to catheterization (hrs) |
|
 | | Primary EP (peak of troponin I) |
|  | | Composite Ischemic Endpoints at 1 month |
|
 | | Safety outcomes at 1 month |
|  | | Hospital stay |
|
 | | Summary: TIMACS and ABOARD |
|  | | Question: Strategy ? |
|
 | | Q: GPIIbIIIa inhibitors ? When ? |
|  | | GPIIbIIIa Inhibitors |
|
 | | Efficacity GPIIBIIIA in NSTE ACS only if PCI !!! |
|  | | N=2022 |
|
 | | If GPIIbIIIa: - Upstream for all high risk NSTE ACS ? - or selectively downstream if PCI ? |
|  | | N=9492 |
|
 | | Delayed Provisional GPIIbIIIa: Same Ischemic benefit Lower bleeding risk |
|  | | 30-day Death or MI Prespecified Subgroups |
|
 | | Summary for GPIIbIIIa |
|  | | Q: GPIIbIIIa inhibitors ? When ? |
|
 | | Q: Antiplatelet Therapy: P2Y12 inhibitors in CCU ? |
|  | | Alternatives Molecules |
|
 | | Montalescot et al. JACC 2006 |
|  | | Q: Antiplatelet Therapy: P2Y12 inhibitors in CCU ? |
|
 | | Antiplatelet Drugs |
|  | | Study Design, Flow and Compliance |
|
 | | Clopidogrel: Double vs Standard Dose Primary Outcome and Components |
|  | | Clopidogrel: Double vs Standard Dose Primary Outcome: PCI Patients |
|
 | | Clopidogrel Double vs Standard Dose Bleeding PCI Population at 30 days |
|  | | Conclusions Clopidogrel Dose Comparison |
|
 | | ACS (STEMI or UA/NSTEMI) & Planned PCI |
|  | | Primary Endpoint: CV Death,MI,Stroke |
|
 | | Balance of Efficacy and Safety |
|  | | ISCHEMIC BENEFIT: subgroups |
|
 | | Diabetic Subgroup |
|  | | Ischemic Risk |
|
 | | BLEEDING RISK: subgroups |
|  | | Tailored for Bleeding Risk ? |
|
 | | P2Y12 inhibitors for PCI/ACS in 2011 |
|  | | Q: Antiplatelet Therapy: P2Y12 inhibitors in CCU ? |
|
 | | Platelet Function Tests |
|  | | Composite of death, non-fatal myocardial infarction, definite stent thrombosis and stroke POPular study JAMA 2010 |
|
 | | Cut-Off values Based on Clinical Endpoints in Prospective Studies |
|  | | Risk for recurrent events concentrated in patients with highest on-treatment reactivity |
|
 | | POPular Risc Score |
|  | | Ticagrelor compared with clopidogrel in patients with acute coronary syndromes – the PLATO trial |
|
 | | Ticagrelor (AZD 6140): an oral reversible P2Y12 antagonist |
|  | | PLATO study design |
|
 | | K-M estimate of time to first primary efficacy event (composite of CV death, MI or stroke) |
|  | | Time to major bleeding – primary safety event |
|
 | | Non-CABG and CABG-related major bleeding |
|  | | Safety = TIMI Major Non-CABG Bleeds (12-15 months) |
|
 | | Conclusions |
|  | | 2011 CURRENT vs PLATO vs TRITON |
|
 | | Platelet Aggregation at 4 hours |
|  | | TRITON and PLATO |
|
 | | Safety = TIMI Major Non-CABG Bleeds (12-15 months) |
|  | | Tailor-made medicine? |
|
 | | Marked interindividual response to antiplatelet drugs |
|  | | Residual or On-Treatment Platelet Reactivity |
|
 | | Do Platelet Function Assays Predict Clinical Outcomes in clopidogrel pretreated patients undergoing elective PCI The POPular-study. JAMA 2010;303:754-62 |
|  | | Tests more physiological shear-dependent |
|
 | | POPular Risk Score |
|  | | Rate of CABG patients and TIMI Major Bleeds |
|
 | | Summmary: P2Y12 inhibition for tomorrow |
|  | | Compliance and ST |
|
 | | With more potent P2Y12 inhibitors: How to reduce Bleeding Risk in ACS ? |
|  | | Low Dose of Aspirin |
|
 | | ASA Dose Comparison Primary Outcome and Bleeding |
|  | | Use of PPI |
|
 | | Radial Access |
|  | | Case |
|
 | | 3/3/2011 |
|  | | 3/3/2011 |
|
 | | Similar for DES |
|  | | MACC with BMS and non-cardiac surgery N=899 |
|
 | | Bleeds with DES and Non-cardiac Surgery |
|  | | Bridging? |
|
 | | Summary for ACS: 2011 |
|  | | Discharge therapy |
|
 | | Tailored Therapy PCI in ACS ? |
|  | | Discontinue antithrombotica |
|
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