TataKelola dan KamSiber Kecerdasan Buatan v022.pdf
0900 0920 Antiplatelet and Anticoaulation Therapy Aleti FINAL(1).pptx
1. Sumith Aleti, MD, MPH, FACC
OHHI Cardiology Group
Antiplatelet and Anticoagulation
Therapy – What You Need to Know
2. Objectives
• Utilize current practice guidelines for the management of
antiplatelet therapy in CAD patients.
• Discuss the selection of different antiplatelet medications
• Determine optimal duration of Dual Antiplatelet therapy
• Assess CV risk vs bleeding risk
• Recognize options of of anticoagulation in atrial fibrillation
5. Aspirin for Primary Prevention
• Aspirin reduces the risk of myocardial Infarction among
men (Physician’s Health Study (PHS)
• Aspirin does not reduce cardiovascular events among
women (Women’s Health Study)
• Aspirin decreases risk of ischemic stroke in woman but
not in men.
• Aspirin does not reduce the risk of adverse CV events in
diabetics (POPADAD study and Japanese PAD study)
• Aspirin reduces the risk of MI and vascular events at the
expense of bleeding (ATT collaboration)
6. Aspirin (81 mg daily or 100 mg every other day) in at risk
women >65 years of age
Aspirin in at risk women <65 years of age for ischemic
stroke prevention
Aspirin in optimal risk women <65 years of age
I IIa IIb III
I IIa IIb III
I IIa IIb III
Aspirin Recommendations
Primary Prevention
Source: Mosca L et al. Circulation 2007;115:1481-1501
7. Aspirin (75-162 mg daily) in [men]* at intermediate risk
(10-year risk of CHD >10%)
For diabetics only for (10-year risk >10%) and for men
>50 years of age or women >60 years of age who have
at least one additional major risk factor
Low-dose aspirin (75-162 mg/day) may be considered
for those with DM at intermediate CVD risk (younger
patients with >1 risk factors* or older patients with no
risk factors*, or patients with a 10-year risk of 5-10%.‡
Aspirin Recommendations (Continued)
Primary Prevention
I IIa IIb III
CHD=Coronary heart disease
*Specific guideline recommendations for men do not exist, but these guidelines are based
on previous general (not gender specific) primary prevention guidelines
Source: Pearson TA et al. Circulation 2002;106:388-391
I IIa IIb III
Includes those with family history of premature CVD,
hypertension, smoking, dyslipidemia, or albuminuria
I IIa IIb III
8. Source: Antithrombotic Trialists’ Collaboration. BMJ 2002;324:71–86
Category % Odds Reduction
Acute MI
Acute CVA
Prior MI
Prior CVA/TIA
Other high risk
CVD
(e.g. unstable angina, heart failure)
PAD
(e.g. intermittent claudication)
High risk of embolism (e.g. Afib)
Other (e.g. DM)
All trials
1.0
0.5
0.0 1.5 2.0
Control better
Antiplatelet better
Effect of antiplatelet treatment* on vascular events**
*Aspirin was the predominant antiplatelet agent studied
**Include MI, stroke, or death
Aspirin Evidence:
Secondary Prevention
Aspirin reduces the risk of adverse cardiovascular events
10. Clopidogrel:
Secondary Prevention
• Clopidogrel provides slightly greater risk reduction than
aspirin
• DAP therapy produces greater benefit when used for 1
year in NSTE-ACS patients
• DAP therapy produces greater benefit when used for 1
year in post PCI patients.
• DAP therapy produces greater benefit in medically
managed STEMI patients
• Routine use of DAP for high risk patients showed no
benefit over aspirin alone.
12. Source: Wiviott SD et al. NEJM 2007;357:2001-2015
Trial to Assess Improvement in Therapeutic Outcomes by
Optimizing Platelet Inhibition with Prasugrel (TRITON-TIMI 38)
0
5
9
60 90 180 270 360 450
HR 0.81, P=0.0004
Prasugrel
Clopidogrel
HR 0.80
P=.001
HR 0.77
P=.001
Days
CV
death,
MI,
or
stroke
%
12.1
9.9
Bleeding Events
C (%) P (%) P-value
TIMI major 1.8 2.4 .03
Life threatening 0.9 1.4 .01
Nonfatal 0.9 1.1 .23
Fatal 0.1 0.4 .002
ICH 0.3 0.3 .74
13,608 patients with high-risk ACS scheduled for PCI randomized to
clopidogrel (300 mg LD and 75 mg MD) or prasugrel (60 mg LD and 10 mg
MD) for a median of 12 months
7
11
ACS=Acute coronary syndrome, ICH=Intracranial
hemorrhage, LD=Loading dose, MD=Maintenance dose
Prasugrel Evidence:
Secondary Prevention
0 30
Prasugrel reduces ischemic events with a higher rate of bleeding
13. Targeted Platelet Inhibition to Clarify the Optimal Strategy to
Medically Manage Acute Coronary Syndromes (TRILOGY-ACS)
Prasugrel Evidence:
Secondary Prevention
HR=0.91, P=0.21
CV
Death,
Nonfatal
MI,
and
Nonfatal
Stroke
(%)
0
10
20
Time (Days)
0 360 720
16.0%
13.9%
Clopidogrel
Prasugrel
Source: Roe, MT et al. NEJM 2012;367:1297-1309
CV=Cardiovascular, MI=Myocardial infarction, NSTE-
ACS=Non-ST-segment elevation acute coronary syndrome
7243 patients with a medically managed NSTE-ACS randomized to
prasugrel (10 mg) or clopidogrel for up to 30 months
Prasugrel does not provide benefit in medically managed NSTE-ACS
14. Prasugrel: Summary
Intervention P2Y12 Choice
Medical management No benefit of prasugrel over clopidogrel,
except in pts undergoing angiography
Invasive management
PCI with no risk of bleeding
complications
Reasonable t prefer prasugrel* over
clopidogrel[1]
In patients ≥75 years of age, <60 kg in weight, or with prior transient ischemic attack
(TIA) or stroke, Prasugrel is not recommended
*In pts with no prior stroke or TIA.
1. Amsterdam EA, et al. Circulation. 2014;130:2354-2394.
16. Platelet Inhibition and Patient Outcomes (PLATO) Study
18,624 patients with a moderate to high risk ACS randomized to clopidogrel
(300-600 mg LD and 75 mg MD) or ticagrelor (180 mg LD and 90 mg twice
daily MD) for 12 months
Source: Wallentin L et al. NEJM 2009;361:1045-1057
Ticagrelor reduces ischemic events with no higher rate of bleeding overall
Days after randomization
0 60 120 180 240 300 360
12
10
8
6
4
2
0
CV
Death,
MI,
or
Stroke
(%)
9.8
11.7 HR 0.84, p=0.001
Clopidogrel
Ticagrelor
Bleeding Events*
C (%) T (%)
TIMI major/year 7.9 7.7
PLATO major/year 11.6 11.2
Life threatening/year 5.8 5.8
Fatal/year 0.3 0.3
ACS=Acute coronary syndrome, CV=Cardiovascular,
LD=Loading dose, MD=Maintenance dose
*No statistically significant differences were observed in bleeding rates overall
Ticagrelor Evidence:
Secondary Prevention
17. Invasive (coronary angiography followed by revascularization)
PLATO: CV Death, MI, or Stroke in ACS Pts
With or Without Invasive Strategy
20
16
12
8
4
0
360
300
240
180
120
60
0
Noninvasive
HR: 0.85 (95% CI: 0.73-1.0)
Invasive
HR: 0.84 (95% CI: 0.75-0.94)
12.0%
14.3%
9.0%
10.7%
Days After Randomization
CV
Death,
MI,
or
Stroke
(%)
Ticagrelor +ASA (n = 6732)
Clopidogrel + ASA (n = 6676)
Noninvasive
Ticagrelor + ASA (n = 2601)
Clopidogrel + ASA (n = 2615)
James SK, et al. BMJ. 2011;342:d3527
18. PEGASUS–TIMI 54: CV Death, MI, or Stroke in
Pts With Prior MI and ≥ 1 Risk Factor*
Bonaca MP, et al. N Engl J Med. 2015;372:1791-1800.
*65 yrs of age or older, diabetes, second prior MI, multivessel CAD, or chronic non-end stage renal
dysfunction.
10
8
6
4
2
0
0 36
6 12 18 24 30
Mos From Randomization
CV
Death,
MI,
or
Stroke
(%)
N = 21,162
Median follow-up: 33 mos 9.0%
7.8%
7.8%
Placebo
Ticagrelor 90 mg
Ticagrelor 60 mg
Ticagrelor 90 mg
HR: 0.85 (95% CI 0.75-0.96;
P = .008)
Ticagrelor 60 mg
HR: 0.84 (95% CI 0.74-0.95;
P = .004)
22. Lets simplify
• Aspirin dose in PCI patients – 81 is enough
• Regardless of stent type ideal duration is 1 year
• DAPT in PCI for Stable ischemic heart disease
• DAPT in PCI for ACS patients
• Bleed risk – (previous bleed on DAPT, on oral
anticoagulation, has coagulopathy etc)
23. Stable Ischemic Heart disease
• DAPT consists of ASA + Clopidogrel
• Bare metal – 1 month minimum
• Current DES stents – 6 months minimum
• If no bleed risk continue longer in both groups.
• May be reasonable to stop P2Y12inh after 3 months if
patient developed significant overt bleeding, or at risk for
severe bleeding complication (e.g. major intracranial
surgery)
24. ACS patients
• At least 12 months for both BMS and DES patients.
• Reasonable to prefer Ticagrelor over Clopidogrel
• Reasonable to prefer Prasugrel over Clopidogrel if
patient not at high bleeding risk and do not have CVA
• If no bleeding complication or bleed risk low, may
continue longer than 12 months.
• DES patients may discontinue P2Y12 after 6 months if
high bleed risk.
26. ACC/AHA Guidelines 2014
• Antithrombotic therapy is recommended for all patients
with atrial fibrillation except those with low risk (grade IA)
• Use CHA2DS2-VASC score to calculate CVA risk in
nonvalvular afib (grade IA)
• Assessment of bleeding risk should be done when
prescribing oral anticoagulation therapy (grade IA)
• Where oral anticoagulation indicated, a DOAC should be
used instead of warfarin (grade IIA)
28. When to Anticoagulate
*AHA/ACC 2014 atrial fibrillation guidelines 28
• Using the CHA2DS2VASC score:
• Score of 0 = no anticoagulation
• Score of 1 = none (if point awarded for gender only), or
aspirin, or oral anticoagulation
• Score of >2 = oral anticoagulation
29. Direct Oral Anticoagulation (DOAC)
Examples
• Direct thrombin inhibitor
– Dabigatran (Pradaxa)
• Direct factor Xa inhibitor
– Rivaroxaban (Xarelto)
– Apixaban (Eliquis)
– Edoxaban (Savaysa)
– Betrixaban (Bevyxxa)
29
30. Warfarin
Preferred for patients with:
• Mechanical heart valves
• Valvular afib: mitral stenosis or mitral valve replacement
• Breastfeeding
• End stage renal disease
30
31. Conclusions
• DAPT is indicated at least for one year after ACS
Duration of antiplatelet therapy is based on ischemic vs
bleed risk
• Newer generation stents, DAPT duration shorter in
special situations
• In patients with prior MI, benefit with extending DAPT
beyond one year
• Calculate bleeding risk for ischemic risk in assessing
duration
