Antithrombotic therapy after pci in atrial fibrillation 2016

Stent e fibrillazione
atriale: singola,
duplice o triplice
terapia
antitrombotica?
F Arrigo, Messina
Arrigo, Messina (Italy) 2016

Prevalenza
con l’età
Trend futuro

104 cohort studies. 587,867 participants with AF
Outcome Relative risk 95% CI
Heart failure 4.99 3.04–8.22
Stroke 2.42 2.17–2.71
CV mortality 2.03 1.79–2.30
Major CV events 1.96 1.53–2.51
Sudden cardiac death 1.88 1.36–2.60
Chronic kidney disease 1.64 1.41–1.91
Ischemic heart disease 1.61 1.38–1.87
Allcause mortality 1.46 1.39–1.53
Peripheral arterial disease 1.31 1.19–1.45
Odutayo A, Wong CX, Hsaio AJ, et al. Atrial fibrillation and risks of cardiovascular disease, renal
disease, and death: systematic review and metaanalysis. BMJ 2016; DOI:10.1136/bmj.i4482
Atrial Fibrillation and Nonstroke Outcomes

RiskAdjusted InHospital Mortality After PCI
Multicenter registry Blue Cross Blue Shield of
Michigan CV Consortium.
• Data for consecutive 113,283 PCI cases from 47
hospitals between 4/2011 and 12/2014.
• A history of AF was present in 13,912 patients (12%).
• Except in rare cases, patients were not taking oral
anticoagulation at the time of PCI
• Patients with a history of AF were more likely to have
inhospital complications, including inhospital
mortality (3% vs. 1%).
Sutton NR et al
2016;68(9):895904.
Outcomes of Patients With
Atrial Fibrillation Undergoing PCI

Multicenter registry Blue Cross Blue Shield of Michigan CV Consortium.
• Data for consecutive 113,283 PCI cases from 47 hospitals between
4/2011 and 12/2014.
• A history of AF was present in 13,912 patients (12%).
• Except in rare cases, patients were not taking oral anticoagulation at the
time of PCI
• Patients with a history of AF were more likely to have inhospital
complications, including inhospital mortality (3% vs. 1%).
RiskAdjusted InHospital Mortality After PCI
Sutton NR et al
2016;68(9):895904.

Sutton NR et al
2016;68(9):895-904.
Risk -Adjusted InHospital Mortality After PCI

Propensity-matched inhospital outcomes of patients with and
without a history of atrial fibrillation (AF) undergoing PCI.

EuroObservationalResearchProgrammeAtrial
Fibrillation (EORP-AF) Pilot General Registry
Europace Advance Access published December 17, 2013
3119 patients from February 2012 to March 2013

Stent e fibrillazione atriale
• Il trattamento più efficace per prevenire il
tromboembolismo nella fibrillazione atriale è
la Terapia Anticoagulante Orale (TAO).
• La terapia più efficace per prevenire la
trombosi intrastent dopo PCI è la doppia
antiaggrezione piastrinica (DAPT) con aspirina
e P2Y12 inibitori.

Go, A. S. et al. JAMA 2001;285:2370-2375.
OAC vs. DAPT
Stroke Subacute stent thrombosis
The ACTIVE Investigators. Lancet 2006;367:1903-12 Bertrand ME et al. Circulation 1998;98:1597-1603

Fibrillazione Atriale
Angioplastica Con
Stent
Rischio
tromboembolie
Trombosi
intrastent
TAO DAPT
Rischio emorragico

FARMACI ANTITROMBOTICI (2016)
operano con meccanismi differenti e talora complementari
• Antiaggreganti piastrinici
– Inibitori COX-2 (Aspirina, Indobufene)
– Inibitori P2Y12 (Ticlopidina, Clopidogrel, Prasugrel, Ticagrelor,
Cangrelor)
– Inibitori PDE III (Dipiridamolo, Cilostazolo)
– Inibitori GP IIb/IIIa (Abcxmab, Tirofiban)
• Anticoagulanti diretti
– Agenti antitrombinici (Irudina, Dabigatran); Inibitori Xa
(Fondaparinux, Rivaroxaban, Edoxaban, Apixaban )
• Anticoagulanti indiretti
– Eparina (non frazionata, a basso peso molecolare);
– Dicumarolici (Warfarin, acenocumarolo, fenprocumone)
• Trombolitici
– Attivatori esogeni ed endogeni del plasminogeno

Options for antithrombotic regimens in patients
with AF undergoing PCI.
P. Cannon et al. RE-DUAL PCI Trial. Clinical Cardiology 2016
Additional
nuances of
these
strategies
could be
applied by
changing the
duration of
antiplatelet
therapy.

Terapia antitrombotica multipla
• Singola terapia antitrombotica
– Aspirina o inibitore P2Y12 o TAO (Warfarin o NOAC)
• Doppia terapia antiaggregante (DAPT)
– Aspirina + inibitore P2Y12
• Doppia terapia antitrombotica (DAT)
• Aspirina o inibitore P2Y12 + TAO (Warfarin o NOAC)
• Tripla terapia antitrombotica (TT)
– Aspirina + inibitore P2Y12 + TAO (Warfarin o NOAC)
• Tripla terapia antiaggregante (TAPT)
– Aspirina + inibitore P2Y12 + Antagonista PAR-1 (Voraxapar) o Inibitore PDE III
(Dip o Cilostazolo)
• Doppia terapia antiaggregante parenterale
– inibitore P2Y12 (Cangrelor) + Tirofiban

Valutazione del rischio
CHA2DS2-VASc
• ScompensoCardiaco 1punto
• Ipertensione a. 1punto
• Età> 75 anni 2punti
• Diabete mellito 1punto
• Pregresso ictus, TIA
o TE 2punti
• StoriadiMal.vasc.
(IMA,PAD,placca) 1punto
• Età65-74anni 1punto
• Sessofemminile 1punto
HAS-BLED
• età> 65 anni
• Ipertensione art.
• anormale funzionalità
renale ed epatica
• Precedente ictus
• storia di sanguinamento (o
predisposizione)
• farmaci che predispongono
a sanguinare
• disturbi da uso di alcol
• INR labile

2014

Haemorrhagic risk Stroke risk Clinical setting Recommendations
Low or moderate
(HAS-BLED 0–2)
Moderate
(CHA2DS2-VASC = 1 in
males)
Stable CAD  At least 4 weeks (no longer than 6 months): triple
therapy of OAC +aspirin + clopidogrel a
 Up to 12th month: OAC and clopidogrel (or aspirin) b
 Lifelong: OACc
High
(CHA2DS2-VASC ≥2)
Stable CAD  At least 4 weeks (no longer than 6 months): triple
therapy of OAC + aspirin + clopidogrel d
 Up to 12th month: OAC and clopidogrel (or aspirin)
 Lifelong: OACc
Moderate
males)
ACS  6 months: triple therapy of OAC + aspirin +
clopidogrel
 Lifelong: OACc
High
(CHA2DS2-VASC ≥2)
ACS  6 months: triple therapy of OAC + aspirin +
clopidogrel
 Lifelong: OACc
.a Combination of OAC + clopidogrel 75 mg/day or DAPT consisting of aspirin 75-mg/day and clopidogrel 75 mg/day may be considered as an alternative.
b Dual antiplatelet therapy consisting of aspirin 75 mg/day and clopidogrel 75 mg/day may be considered as an alternative.
c Alone or combined with single antiplatelet therapy only in very selected cases (e.g. stenting of the left main, proximal bifurcation, recurrent MIs etc).
d Combination of OAC and clopidogrel 75 mg/day may be considered as an alternative.
2014

7. TheACStrialswere underpowered to demonstrate a reduction in stroke risk by usingNOACsin
combination with (dual) antiplatelet therapy in non-AF patients.
8. Given the absence of new data from RCTs and the outcome data coming from‘real-world’
registries, it appears questionable to consider the potential risk of MI as a criterion for
selecting the most appropriate NOAC agent in a patient with non-valvular AF. The available
data do not suggest that there is a need to switch patients on dabigatran to one of the other
NOACs in the event of an ACS developing in a patient with AF.
9. Conversely, in an ACS patient who develops new onset AF, and is at high stroke
risk,OACshould be started, whether with a VKA or NOAC. Limited data suggest that use of the
new P2Y12 inhibitors would increase the risk of major bleeding, and thus, clopidogrel would
be the preferred P2Y12 inhibitor.
Haemorrhagic risk Stroke risk Clinical setting Recommendations
High
(HAS-BLED ≥3)
Moderate
males)
Stable CAD  12 months: OAC and clopidogrel 75 mg/dayb
 Lifelong: OACc
High
(CHA2DS2-VASC ≥2)
Stable CAD  4 weeks: triple therapy of OAC + aspirin +
clopidogrel d
 Lifelong: OACc
Moderate
males)
ACS  4 weeks: triple therapy of OAC + aspirin +
clopidogrel a
 Lifelong: OACc
High
(CHA2DS2-VASC ≥2)
ACS  4 weeks: triple therapy of OAC + aspirin +
clopidogrel a
 Lifelong: OACc
a Combination of OAC + clopidogrel 75 mg/day or dual antiplatelet therapy consisting of aspirin 75-mg/day and clopidogrel 75 mg/day may be considered
as an alternative.
b Dual antiplatelet therapy consisting of aspirin 75 mg/day and clopidogrel 75 mg/day may be considered as an alternative.
c Alone or combined with single antiplatelet therapy only in very selected cases (e.g. stenting of the left main, proximal bifurcation, recurrent MIs etc).
d Combination of OAC and clopidogrel 75 mg/day may be considered as an alternative.
2014

•rischio emorragico alto
• TT per 1 mese, poi DAT fino a 1 anno
•rischio emorragico moderato/basso
• TT per 6 mesi, poi DAT fino a 1 anno
Sindromi Coronariche Acute
indipendentemente dal rischio trombotico
2014

•rischio emorragico e trombotico alto
• TT per 1 mese, poi DAT fino a 1 anno
•rischio emorragico alto e trombotico moderato/basso
• DAPT per 12 mesi
•rischio emorragico moderato/basso
(indipendentemente dal rischio trombotico)
• TT almeno per 1 mese (non più di 6) poi DAT (1 anno)
CAD stabile
2014

Antithrombotic therapy after an ACS in Afib patients
requiring anticoagulation.
2016
2016 ESC Guidelines for the management of atrial Fibrillation. Arrigo, Messina (Italy) 2016

Antithrombotic therapy after elective PCI in Afib
patients requiring anticoagulation.
20162016

Recommendations for combination therapy with
oral anticoagulants and antiplatelets
2016

2014 Guidelines from the AHA, ACC, HRS, ACCP
J Am Coll Cardiol 2014; 64: 2246-2280
Class I
• 10. For patients with AF without mechanical heart valves who require
interruption of warfarin or new anticoagulants for procedures, decisions
about bridging therapy (LMWH or unfractionated heparin) should balance
the risks of stroke and bleeding and the duration of time a patient will not be
anticoagulated. (Level of Evidence: C)
Class IIb
• 3. In patients with AF undergoing PCI, BMS may be considered to minimize
the required duration of dual antiplatelet therapy. Anticoagulation may be
interrupted at the time of the procedure to reduce the risk of bleeding at the
site of peripheral arterial puncture. (Level of Evidence: C)
• 4. Following coronary revascularization (percutaneous or surgical) in patients
with AF and a CHA2DS2-VASc score of 2 or greater, it may be reasonable to use
clopidogrel (75 mg once daily) concurrently with oral anticoagulants but
without aspirin. (Level of Evidence: B)
2014 Guidelines for the management of patients
with atrial fibrillation from the AHA, ACC, HRS, ACCP

Stephen Rechenmacher e James Fang dell’Utah Health
Sciences
Center in una ampia review pubblicata sul JACC del 22
settembre, in cui si definiscono tre principi
fondamentali:
•Bridging procedure
Rechenmacher S, Fang J. J Am Coll Cardiol 2015;66:1392–403

Bridging procedure
review in cui si definiscono tre principi fondamentali:
• la TAO non deve essere interrotta nelle procedure a
basso rischio emorragico
• la bridging therapy non deve mai essere proposta
nei pazienti a basso rischio di eventi
tromboembolici
• la bridging therapy deve essere limitata ai casi ad
alto rischio tromboembolico (TE) e rischio
emorragico basso o intermedio

• The actual rate of periprocedural TE for unbridged OAC interruptions is rare,
estimated at approximately 0.53% from our review of over 23,000 OAC
interruptions in 70 studies from 1966 to 2015
CLOTTING AND BLEEDING RISK IN THE
PERIPROCEDURAL PERIOD

• Rates of bleeding and TE vary by OAC indication (Figure 1B). For atrial fibrillation,
an individual’s daily risk of stroke or transient ischemic attack can be approximated
by dividing the annual stroke risk by 365 days.
CLOTTING AND BLEEDING RISK IN THE
PERIPROCEDURAL PERIOD
atrial
fibrillation

Trials e registri
Isar TRIPLE TT 6 sett vs 6 mesi
WOEST non aspirina
Sambola A TT vs DT nell’anziano
The ROCKET AF Trial (NOAC)
The ACTION Registry–GWTG TT vs DAPT

ISAR-TRIPLE trial
• endpoint primario
– la durata più breve (6 settimane) non è superiore
a 6 mesi di trattamento
• 9,8% vs. 8,8% (HR 1.14, 95% CI 0.68-1.91, p = 0,63)
• endpoint secondari
– eventi trombotici (morte cardiaca, infarto miocardico, ictus
ischemico, e trombosi dello stent )
• 4.0% vs 4.3%, p = 0.87
– eventi emorragici
• 5.3% vs 4.0%, p = 0.44
Duration of Triple Therapy in Patients Requiring Oral Anticoagulation After
Drug-Eluting Stent Implantation. The ISAR-TRIPLE Trial
Fiedler, KA et al. J Am Coll Cardiol 2015;65:1619–29

ISAR-TRIPLE trial
Duration of Triple Therapy in Patients Requiring Oral Anticoagulation After
Drug-Eluting Stent Implantation. The ISAR-TRIPLE Trial
Fiedler, KA et al. J Am Coll Cardiol 2015;65:1619–29
Cumulative Incidence of the Primary, Secondary Ischemic, and Secondary Bleeding Endpoints
(A) primary endpoint (B) secondary ischemic endpoint
(C) Secondary bleeding endpoint
(A) primary endpoint (cumulative incidence of death, myocardial
infarction, stent thrombosis, stroke or TIMI major bleeding)
(B) secondary ischemic endpoint (cardiac death, myocardial
infarction, stent thrombosis, or ischemic stroke),
(C) secondary bleeding endpoint (TIMI major bleeding) at 9
months.
HR = hazard ratio.
Months After Randomization

Go, A. S. et al. JAMA 2001;285:2370-2375.
Use of clopidogrel with or without aspirin in patients
taking OAC and undergoing PCI
WOEST Dewilde WJ et al. Lancet 2013;381:1107-15
1° endpoint – Safety
(total bleeding)
2° endpoint - Efficacy
(stroke, death, MI, re-PCI/CABG, stent thrombosis)
• Double therapy group (n. 279): OAC + 75mg Clopidogrel
• Triple therapy group (n. 284): OAC + 75mg Clopidogrel + 80mg ASA
P=0.0001
HR=0.36 95%CI[0.26-0.50]
p=0.025
HR=0.60 95%CI[0.38-0.94]

Impact of Triple Therapy in Elderly Patients
with Atrial Fibrillation Undergoing PCI
Sambola A et al. PLOS ONE | DOI:10.1371/journal.pone.0147245 January 25, 2016
Influence of triple therapy (TT) at discharge in patients ≥75 years.
Kaplan-Meier survival curves during 1-year follow-up .
Survival free of embolic events Survival free of bleeding events
Survival curves for thromboembolic events diverged very early (before 30 days),
but remained quite parallel afterwards, while the curves for bleeding events
showed a continuous drop in events over time.

.
Sarafoff N et al. J Am Coll Cardiol 2013;61:2060-6
HR 1.4 (95% CI 0.3-6.1; p= 0.61)HR 4.6 (95% CI 1.9-11.4; p<0.001)
Triple therapy of VKA + aspirin + clopidogrel/prasugrel after PCI
BleedingBleeding MACCE

• Treatment group of the ROCKET AF trial (Rivaroxaban
compared with VKA).
• 153 patients (1.1%) underwent PCI during a median
806 days of follow-up.
• Study drug was continued during PCI in 81% of
patients.

The ROCKET AF Trial
JACC Cardiovasc Interv. 2016 Aug 22;9(16):1694-702

Triple Therapy Among Older Pts With AMI and AF.
The ACTION Registry–GWTG
• The ACTION Registry–GWTG is a national quality
improvement registry capturing data on
consecutive MI patients treated at >500 hospitals
in the United States.
• Among 4,959 MI patients presenting with a
history of AF who were treated with PCI, 27.6%
(n = 1,370) were discharged on triple therapy
(warfarin + DAPT), and 72.4% (n = 3,589) were
discharged on DAPT (aspirin and a P2Y12
antagonist)
Hess, C.N. et al. J Am Coll Cardiol. 2015; 66(6):616–27. Arrigo, Messina (Italy) 2016

Hess, C.N. et al. J Am Coll Cardiol. 2015; 66(6):616–27.
Outcomes According to Triple Therapy Versus DAPT
2-year post-discharge MACE (all-cause mortality , MI readmission, and stroke
readmission), and bleeding requiring hospitalization .

Hess, C.N. et al. J Am Coll Cardiol. 2015; 66(6):616–27.
Acute Cerebrovascular Events
According to Triple Therapy Versus DAPT

Bleeding in atrial fibrillation patients following myocardial infarction
and coronary intervention: a nationwide cohort study
• Subjects with AF hospitalized for Myocardial
Infarction (n. 8775 - 76.4%) or PCI (n. 2705 - 23.6%).
• 1521 (17.3%) patients of the group with MI had a PCI
performed within 1 week.
• Inclusion criteria were ongoing antithrombotic
treatment in subjects alive 7 days after discharge,
and no registration with diagnosis of bleeding, MI or
ischemic stroke during the quarantine period.
Lamberts M et al. Circulation 2012;126:1185–1193
Nationwide registries in Denmark 2001 - 2009

Crude incidence rates of fatal and nonfatal bleeding according
to antithrombotic regimen following inclusion.
• Triple therapy includes ASA,
clopidogrel, and VKAs;
• VKA single antiplatelet
therapy includes VKA + ASA
or clopidogrel;
• DAPT includes ASA and
clopidogrel;
• VKA monotherapy includes
only VKA;
• Single antiplatelet therapy
includes ASA or clopidogrel.

Thromboembolic and bleeding outcomes following MI or PCI in
AF patients according to type of antithrombotic treatment
regimen.
• Triple therapy includes ASA,
clopidogrel, and VKAs;
• VKA single antiplatelet
therapy includes VKA + ASA
or clopidogrel;
• DAPT includes ASA and
clopidogrel;
• VKA monotherapy includes
only VKA;
• Single antiplatelet therapy
includes ASA or clopidogrel.
DAT
DAT

Rates of primary and secondary end points for patients
receiving clopidogrel and OAC and TT at 1 year.
• Am J Cardiol. 2015 May 1;115(9):1185-93.
TT
TT
DAT
DAT

Rates of primary and secondary end points for patients
receiving clopidogrel and aspirin and TT at 1 year.
• Am J Cardiol. 2015 May 1;115(9):1185-93.
TT
TT
DAPT
DAPT

Meta-analysis of RCT and observational results
in patients undergoing PCI
triple therapy (TT)
(OAC +aspirin+clopidogrel)
dual-antiplatelet therapy (DAPT)
(aspirin+clopidogrel)
dual therapy (DAT)
(OAC +clopidogrel)
• DAPT vs TT >>
reduction of major
bleeding and no
increased risk of MACE
• DAT vs TT >> reduction
of bleeding, without
affecting rates of MACE
• Am J Cardiol. 2015 May 1;115(9):1185-93.
DAT vs TT
DAPT vs TT

A proposito di Tripla terapia
(OAC +ASA + P2Y12i)
• La doppia terapia (OAC + P2Y12i) è preferibile
• riduce significativamente la mortalità per
qualunque causa e i sanguinamenti (WOEST
trial)
• Riduce i sanguinamenti a parità di effetto sugli
Eventi CV (Metanalisi, ACTION Registry–GWTG)
• la durata della TT per 6 settimane è sufficiente
• uguale protezione antitrombotica e tasso di
emorragie nel confronto tra 6 settimane e 6
mesi (ISAR-TRIPLE trial)

La doppia terapia
 DAP (OAC + P2Y12i) :
 il Clopidogrel è preferibile all’aspirina e al
prasugrel in associazione a OAC
 Sono in corso trials con Ticagrelor e NOAC
 DAPT (P2Y12i + aspirina):
 indicata solo in pazienti a basso rischio
trombotico (CAHDS 0-1)

scenari

Scenario 1a
a NOAC al dosaggio efficace più basso + ASA + Clopidogrel
b prasugrel e ticagrelor non dovrebbero essere usati, a meno di provato insuccesso di aspirina +
clopidogrel
Rischio emorragico
basso/intermedio
Rischio emorragico alto
CAD stabile 0 -1 mesi Tripla Terapia a
1-12 mesi DAT (NOAC+ Clo)b
>12 mesi NOAC
0 -1 mesi Tripla Terapia a
1-6 mesi DAT (NOAC+ Clo) b
> 6 mesi NOAC
SCA 0 -6 mesi Tripla Terapia a
6-12 mesi DAT (NOAC+ Clo)b
>12 mesi NOAC
0 -1 mesi Tripla Terapia a
1-12 mesi DAT (NOAC+ Clo) c
> 12 mesi NOAC
Pz con FA a rischio trombotico basso/moderato
(CHA2DS2-VASc ≤2) non in trattamento anticoagulante
• DAPT con aspirina + ticagrelor (Clopidogrel se
rischio emorragico alto) per 6 mesi
• Dopo, valutare l’indicazione a NOAC

Scenario 1b
a NOAC al dosaggio efficace più basso + ASA + Clopidogrel
b NOAC + aspirina o clopidogrel
Rischio emorragico
basso/intermedio
CAD stabile 0 -1 mesi Tripla Terapia a
1 -12 mesi DAT b
> 12 NOAC
0-1 mesi Tripla Terapia a
1 - 6 mesi DAT b
> 6 mesi NOAC
SCA 0 -6 mesi Tripla Terapia a
6 -12 mesi DAT b
>12 NOAC
0 - 1 mesi Tripla terapia a
1 -12 mesi DAT b
> 12 mesi NOAC
Pz con FA a rischio trombotico alto
(CHA2DS2-VASc>2) non in trattamento anticoagulante
• TT (NOAC al dosaggio efficace più basso+ASA+Clopidogrel)
per 12 mesi
• Se rischio emorragico alto, DAT con NOAC + Clopidogrel
per 6 mesi
• Dopo valutare l’indicazione a NOAC

Scenario 2
a TAO + ASA + Clopidogrel. Se NOAC ridurre il dosaggio.
b TAO + aspirina o clopidogrel
c In pz ad alto rischio coronarico può essere presa in considerazione la DAT con TAO e aspirina
o clopidogrel
Rischio emorragico
basso/intermedio
SCAD 1-30 gg Tripla Terapia a
1-12 mesi DAT b
>1 anno TAO monoterapia c
1-30 gg Tripla Terapia a
1-6 mesi DAT b
>6 mesi TAO monoterapia c
SCA 0-6 mesi Tripla Terapia a
6-12 mesi DAT b
1-30 gg Tripla Terapia a
1-12 mesi Doppia Terapia b
Pz con FA in trattamento anticoagulante
(AVK con INR corretto o NOAC)
• DAT con TAO + Clopidogrel per 1 anno
• Se rischio emorragico alto BMS e DAT per 1 mese
• Dopo, TAO monoterapia

Scenario 3
Non indicazioni specifiche nelle linee guida
Pz con FA in trattamento anticoagulante
con AVK e INR elevato
• CAD stabile
• Posporre la procedura fino a regolarizzazione INR
• SCA
• solo Clopidogrel fino a normalizzazione INR, poi
reintrodurre TAO a dosi opportune
EuroObservationalResearchProgrammeAtrial
Fibrillation (EORP-AF)
Whole
cohort
Paroxysmal Persistent AF Permanent P value
Labile INRs (%) (if on VKA only) =>.without
condition
20.2 28.0 12.5 27.8 0.272

Quali e quanti farmaci usiamo e per quanto tempo?
Una risposta valida per tutti non esiste e la gestione della
terapia antitrombotica è complessa e spesso
individuale.
Le principali variabili da considerare sono
• Età
• Sindrome clinica
• Rischio tromboembolico
• Rischio emorragico
• Terapia antitrombotica precedente
• Il tipo di stent

La gestione del paziente con fibrillazione
atriale e Sindrome Coronarica Acuta (SCA) o
intervento coronarico percutaneo (PCI) è una
sfida della pratica clinica.
Il punto critico è trovare l’equilibrio ottimale per
prevenire gli eventi trombotici, come la
trombosi dello stent e lo stroke cardioembolico,
senza aumentare il rischio di eventi emorragici
maggiori.
La rapida evoluzione farmacologica e
tecnologica rende spesso superati i risultati
dei trial clinici di riferimento.

Grazie per
l’attenzione
Stent e fibrillazione atriale: singola,
duplice o triplice terapia antitrombotica?
LVIII congresso della sezione
regionale siciliana della Società
Italiana di Cardiologia
Roccalumera 17 – 19 novembre 2016

Go, A. S. et al. JAMA 2001;285:2370-2375.
Strategie per evitare il rischio emorragico
1 Ridurre il dosaggio di OAC (target INR 2.0-2.5)
2. Ridurre la durata della Triplice Terapia (1 - 3 mesi)
3.
Somministrare di routine farmaci gastroprotettivi
(PPIs)

Antithrombotic therapy after pci in atrial fibrillation 2016

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