Este documento resume varios estudios recientes en cardiología intervencionista y farmacología. Resume los hallazgos clave de los estudios Montalescot, Italic Trial, ISAR SAFE y DAPT Trial sobre la duración óptima de la terapia antiplaquetaria dual después de la colocación de stents. También resume los resultados del estudio MATRIX sobre la eficacia y seguridad de la bivalirudina versus heparina no fraccionada. Además, menciona varios estudios en curso sobre el pretratamiento, oxígeno en
Flashcard Anatomía del Craneo: Neurocráneo y Vicerocráneo.
Reunion Anual Madeira 2015 Estudios en Cardiología Intervencionista desde el último Congreso FARMACOLOGÍA
1. Estudios en Cardiología Intervencionista
desde el último Congreso
FARMACOLOGÍA
Dr. Juan Miguel Ruiz Nodar
Hemodinámica y Cardiología Intervencionista
Hospital General Universitario de Alicante
Madeira. 11 de junio de 2015
2. Conflicto de intereses
He recibido ayudas para Investigación o pagos por Cursos o Conferencias de:
Abbott
AstraZeneca
Daichi
Fundación Gent x Gent
Lilly
Medtronic
St.Jude
3. Guías de revascularización coronaria 2014
Guías de revascularización miocárdica. EHT (29 agosto 2014) doi:10.1093/eurheartj/ehu278
12. ¿Debemos acortar o prolongar la DAPT?
< 6
meses
>12
meses
No diferencias en
eventos hemorrágicos
e isquemicos entre 6 y
12 meses
Similares resultados
clínicos entre 6 y 12
meses
La DPAT a 30 meses
reduce la trombosis del
stent y eventos
cardiovasculares
28. NAG • AVOID
• Oxígeno en el IAM
Bendavia
• EMBRACE STEMI
• Lesión de reperfusión
REG-1
• REGULATE-PCI
• REG 1 vs Bivalirudina
en PCI
Metoprolol
• METOCARD
•Metoprolol antes de la
pPCI
No diferencias en eventos isquemicos pero tampoco reducción de los hemorragicos
Y cuando no hay aumento de eventos hemorrágicos es que son poblaciones de bajo riesgo
Comprehensive Meta-Analysis of Safety and Efficacy of Bivalirudin Versus Heparin With or Without Routine Glycoprotein IIb/IIIa Inhibitors in Patients With Acute Coronary Syndrome
Eliano Pio Navarese, MD, PhD∗; Volker Schulze, MD†; Felicita Andreotti, MD, PhD‡; Mariusz Kowalewski, MD‡; Michalina Kołodziejczak, MD‡; David E. Kandzari, MD#; Tienush Rassaf, MD, PhD†; Bartosz Gorny, MD‡; Maximilian Brockmeyer, MD†; Christian Meyer, MD, PhD†; Sergio Berti, MD∗; Jacek Kubica, MD, PhD‡; Malte Kelm, MD†; Marco Valgimigli, MD, PhD††
[+-] Author Information∗ Invasive Cardiology, National Research Council Institute of Clinical Physiology, Pisa, Italy † Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany ‡ Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Poland and Germany # Piedmont Heart Institute, Atlanta, Georgia †† Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
J Am Coll Cardiol Intv. 2015;8(1_PB):201-213. doi:10.1016/j.jcin.2014.10.003
Published online
Article
Figures
Tables
References
Supplemental Materials
text A A A
Abstract
Objectives The aim of this meta-analysis was to compare the 30-day safety and efficacy of bivalirudin with those of heparin with or without routine administration of a glycoprotein IIb/IIIa inhibitor (GPI) in patients with acute coronary syndrome (ACS).
Background Bivalirudin has been a mainstay of anticoagulation in patients with ACS compared with heparin. The extent to which trial results have been affected by the coadministration of heparin with a GPI, however, remains unclear.
Methods A total of 13 randomized, controlled trials involving 24,605 patients were included.
Results There was no significant difference in 30-day mortality or myocardial infarction rate with bivalirudin compared with heparin with or without routine GPI administration. A reduction of 30-day major bleeding was observed with bivalirudin compared with heparin that was significant when GPI was routinely administered (odds ratio [OR]: 0.52, 95% confidence interval [CI]: 0.45 to 0.60), p < 0.001) but not with provisionally administered GPI (OR: 0.66, 95% CI: 0.33 to 1.32; p = 0.24). The occurrence of stent thrombosis (ST) at 30 days was significantly increased with bivalirudin compared with heparin plus routinely administered GPI (OR: 1.67, 95% CI: 1.13 to 2.45, p = 0.02), but not compared with heparin plus provisionally administered GPI (OR: 2.08, 95% CI: 0.35 to 12.32, p = 0.42). The rate of acute ST (≤24 h), however, was almost 4.5-fold higher with bivalirudin compared with heparin with or without GPI, whereas the rate of subacute ST (24 h to 30 days) did not differ significantly.
Conclusions Overall, bivalirudin in ACS patients is associated with a significant reduction of major bleeding compared with heparin plus routinely administered GPI, but with a marked increase in ST rates compared with heparin with or without GPI
Comprehensive Meta-Analysis of Safety and Efficacy of Bivalirudin Versus Heparin With or Without Routine Glycoprotein IIb/IIIa Inhibitors in Patients With Acute Coronary Syndrome
Eliano Pio Navarese, MD, PhD∗; Volker Schulze, MD†; Felicita Andreotti, MD, PhD‡; Mariusz Kowalewski, MD‡; Michalina Kołodziejczak, MD‡; David E. Kandzari, MD#; Tienush Rassaf, MD, PhD†; Bartosz Gorny, MD‡; Maximilian Brockmeyer, MD†; Christian Meyer, MD, PhD†; Sergio Berti, MD∗; Jacek Kubica, MD, PhD‡; Malte Kelm, MD†; Marco Valgimigli, MD, PhD††
[+-] Author Information∗ Invasive Cardiology, National Research Council Institute of Clinical Physiology, Pisa, Italy † Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany ‡ Systematic Investigation and Research on Interventions and Outcomes (SIRIO) MEDICINE Research Network, Poland and Germany # Piedmont Heart Institute, Atlanta, Georgia †† Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
J Am Coll Cardiol Intv. 2015;8(1_PB):201-213. doi:10.1016/j.jcin.2014.10.003
Published online
Article
Figures
Tables
References
Supplemental Materials
text A A A
Abstract
Objectives The aim of this meta-analysis was to compare the 30-day safety and efficacy of bivalirudin with those of heparin with or without routine administration of a glycoprotein IIb/IIIa inhibitor (GPI) in patients with acute coronary syndrome (ACS).
Background Bivalirudin has been a mainstay of anticoagulation in patients with ACS compared with heparin. The extent to which trial results have been affected by the coadministration of heparin with a GPI, however, remains unclear.
Methods A total of 13 randomized, controlled trials involving 24,605 patients were included.
Results There was no significant difference in 30-day mortality or myocardial infarction rate with bivalirudin compared with heparin with or without routine GPI administration. A reduction of 30-day major bleeding was observed with bivalirudin compared with heparin that was significant when GPI was routinely administered (odds ratio [OR]: 0.52, 95% confidence interval [CI]: 0.45 to 0.60), p < 0.001) but not with provisionally administered GPI (OR: 0.66, 95% CI: 0.33 to 1.32; p = 0.24). The occurrence of stent thrombosis (ST) at 30 days was significantly increased with bivalirudin compared with heparin plus routinely administered GPI (OR: 1.67, 95% CI: 1.13 to 2.45, p = 0.02), but not compared with heparin plus provisionally administered GPI (OR: 2.08, 95% CI: 0.35 to 12.32, p = 0.42). The rate of acute ST (≤24 h), however, was almost 4.5-fold higher with bivalirudin compared with heparin with or without GPI, whereas the rate of subacute ST (24 h to 30 days) did not differ significantly.
Conclusions Overall, bivalirudin in ACS patients is associated with a significant reduction of major bleeding compared with heparin plus routinely administered GPI, but with a marked increase in ST rates compared with heparin with or without GPI
The MATRIX antithrombin analysis addressed the question of whether bivalirudin with bailout GP IIb/IIIa inhibitor (GPI) use was superior to UFH with planned or bailout GPI use in reducing MACE or NACE. The superiority of the newer agent, bivalirudin, first established in STEMI patients in the HORIZONS and EUROMAX trials, was called into question last year with the results from the single-centre HEAT-PPCI trial. In all, 3610 patients were randomized to a bivalirudin strategy and 3603 randomized to a UFH-based strategy.
In MATRIX, for both co-primary end points, MACE and NACE, bivalirudin was not statistically superior to UFH at 30 days. Valgimigli speculated that this may have been due to the higher-than-expected rate of MI (including periprocedural MI) in both groups at 8.5%. Several secondary end points, however, favoured bivalirudin including major bleeding (1.4% vs. 2.5%, p=0.001) and all-cause death (1.7% vs. 2.3%, p=0.042).
Definite stent thrombosis, however, was more common in the bivalirudin-treated patients (1.0% vs. 0.6%, p=0.048).
Bivalirudin in MATRIX was dosed according to drug labelling, which included a prolonged infusion by operator discretion, Valgimigli said. UFH was given pre-admission to approximately one-third of both patient groups, which Valgimigli pointed out was guideline recommended. UFH dose during PCI was 70-100 units per kg in patients not receiving GPIs and at 50-70 units per kg in patients receiving GPIs.
GPIs were ultimately given periprocedurally to 4.6% of the bivalirudin group and 25.8% of the UFH group.
Valgimigli was careful to stress that both co-primary end points in the MATRIX antithrombin analysis were neutral, but highlighted the benefits of bivalirudin in reducing deaths (driven by CV fatalities) and bleeding events. The number needed to treat to prevent one death, he noted, was 150.
Rapid Onset of Action
Predictable Dose-Response
High Anti-Thrombotic Efficacy
Quick Reversibility or Titratability
In patients with anterior Killip class II STEMI undergoing pPCI, early IV metoprolol before reperfusion resulted
in higher long-term LVEF, reduced incidence of severe LV systolic dysfunction and ICD indications, and fewer
heart failure admissions. (Effect of METOprolol in CARDioproteCtioN During an Acute Myocardial InfarCtion. The
METOCARD-CNIC Trial; NCT01311700) (J Am Coll Cardiol 2014;63:2356–62)