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Anticoagulation in pci

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Anticoagulation in pci

  1. 1. Dr. Dev PahlajaniDr. Dev Pahlajani MD,FACC,FSCAIMD,FACC,FSCAI ANTICOAGULATION IN COMPLEX PCI Chief of Interventional cardiology Breach Candy Hospital and Consultant Cardiologist Nanavati Heart Institute,Mumbai
  2. 2. Anticoagulation in complex PCI STEMI,NSTEMI COMPLEX ANATOMY CTO,BIF.MULTIPLE STENTS NEED FOR DAPT+OAC PROSTHETIC VALVE AFIB,LV THROMBUS +TIA
  3. 3. Major Bleeding is Associated with an Increased Risk of Hospital Death in ACS Patients Moscucci et al.Moscucci et al. Eur Heart JEur Heart J 2003;24:1815-232003;24:1815-23 GRACE Registry in 24,045 ACS patientsGRACE Registry in 24,045 ACS patients *After adjustment for comorbidities, clinical presentation and hospital therapies*After adjustment for comorbidities, clinical presentation and hospital therapies **p<0.001 for differences in unadjusted death rates**p<0.001 for differences in unadjusted death rates OR (95% CI)OR (95% CI) 1.64 (1.18 to 2.28*)1.64 (1.18 to 2.28*) 00 Overall ACSOverall ACS UAUA NSTEMINSTEMI STEMISTEMI 1010 2020 3030 4040 **** **** **** **** 5.15.1 18.618.6 3.03.0 16.116.1 5.35.3 15.315.3 7.07.0 22.822.8 Inhospitaldeath(%)Inhospitaldeath(%) In hospital major bleedingIn hospital major bleeding YesYesNoNo
  4. 4. Blood Transfusion is Associated with an Increased 30-Day Mortality in NSTEMI Rao et al.Rao et al. JAMAJAMA 2004;292:1555-622004;292:1555-62 N=24,112 ACS patients from GUSTO IIb, PURSUIT and PARAGONN=24,112 ACS patients from GUSTO IIb, PURSUIT and PARAGON *Adjusted for baseline characteristics, bleeding and transfusion propensity and nadir hematocrit*Adjusted for baseline characteristics, bleeding and transfusion propensity and nadir hematocrit HR=3.94*;HR=3.94*; 95%CI: 3.26 to 4.7595%CI: 3.26 to 4.75 30-day30-day death ratedeath rate TransfusionTransfusion No TransfusionNo Transfusion Log-rankLog-rank p<0.001p<0.001 00 0.020.02 0.040.04 0.060.06 0.080.08 0.100.10 55 1010 1515 2020 2525 3030 DayDay 8.00%8.00% 3.08%3.08% CumulativemortalityCumulativemortality
  5. 5. Potential Mechanisms for the Higher Morbidity/Mortality Associated with Bleeding 1. Cessation of antithrombotic therapies after bleeding may increase subsequent ischemic events 2. Patients who bleed may have an heightened inflammatory state 3. Adverse effects of hypotension 4. Adverse effects of transfusion 5. Common risk factors for bleeding and adverse outcome 1. Gibbons & Fuster. N Engl J Med 2006;354:1524-7 2. Califf. JAMA 2006;295:1579-80 3. Jozic J. AJC 2006;98:36M
  6. 6. Sweet spot for P2Y12 inhibition M.Valgimigli, EUROPCR, 2013
  7. 7. Plethora of choices for Antithrombotic therapy • Anticoagulants: UFH LMWH Fonda Bival • Antiplatelets: ASA Clopidogrel (dose) Prasugrel (dose) Ticagrelor • IV antiplatelets : None AbcixEpt/ Tiro (timing) • Oral anticoagulant None Rivaroraban
  8. 8. Anticoagulation strategies in complex PCI OAC WITH ? DAPT? TOAT? SAPT PPCI BIVALURIDIN,LMWH
  9. 9. Primary Outcome Measures (ITT)Primary Outcome Measures (ITT) 12.1 8.3 5.5 9.2 4.9 5.4 0 5 10 15 20 Net adverse clinical events Major bleeding* MACE** 30dayeventrates(%) Heparin + GPIIb/IIIa inhibitor (N=1802) Bivalirudin monotherapy (N=1800) RR = 0.99 [0.76, 1.30]RR = 0.99 [0.76, 1.30] PPsupsup = 0.95= 0.95 RR = 0.60 [0.46, 0.77]RR = 0.60 [0.46, 0.77] PPsupsup ≤ 0.0001≤ 0.0001 RR = 0.76 [0.63, 0.92]RR = 0.76 [0.63, 0.92] PPsupsup = 0.005= 0.005 1° endpoint 1° endpoint *Not related to CABG*Not related to CABG **MACE = All cause death, reinfarction,**MACE = All cause death, reinfarction, ischemic TVR or strokeischemic TVR or strokeStone GW, et al.Stone GW, et al. N Engl J MedN Engl J Med. 2008 May 22;358(21):2218-30. 2008 May 22;358(21):2218-30
  10. 10. HORIZONS AMI—30-Day Stent Thrombosis (N=3,124) UFH + GP IIb/IIIaUFH + GP IIb/IIIa (N=1553)(N=1553) BivalirudinBivalirudin (N=1571)(N=1571) PP ValueValue ARC definite orARC definite or probable*probable* 1.9%1.9% 2.5%2.5% 0.330.33 DefiniteDefinite 1.4%1.4% 2.2%2.2% 0.110.11 ProbableProbable 0.5%0.5% 0.3%0.3% 0.260.26 AcuteAcute (≤24 hrs)(≤24 hrs) 0.3%0.3% 1.3%1.3% 0.00090.0009 SubacuteSubacute (>24 hrs – 30d)(>24 hrs – 30d) 1.7%1.7% 1.2%1.2% 0.300.30 Stone GW, et al. N Engl J Med. 2008 May 22;358(21):2218-30
  11. 11. WHY IS THERE AN EXCESS OF EARLY STENT THROMBOSIS IN HORIZONS AMI ? Clopidogrel BIVALIRUDIN ASPIRIN PPCI 24hrs
  12. 12. Bivalirudin plasma levels in PCI • Plasma concentrations vs time(25 min elimination half life) • Bolus plus infusion (for the duration of the procedure) is required dosing
  13. 13. HORIZONS: Impact of pre-randomized heparin on Acute Stent Thrombosis
  14. 14. Enrolment 7962 consecutive patients enrolled for elective or primary PCI in 144 hospitals across 23 countries
  15. 15. ENOXAPARIN ALL COMERS BCH ( N = 1111) NON PAMI ( N = 1038) PAMI ( N = 73) NO GP IIb (578) ANGIOSEAL 105 GP II b (312 ) ANGIOSEAL 45 NO GP II b 43 NO MAJOR BLEED GP II b (30) 1 DIED OF GI BLEED NO GP II b 43 NO MAJOR BLEED
  16. 16. Independent predictors of bleeding
  17. 17. Antiplatelet strategy in patients on OAC • Should we stop or continue OAC pre PCI? • Should we bridge with heparin? • Post PCI triple drug therapy or dual drug ?
  18. 18. Peri procedural management P. Karjalainen, EUROPCR, 2013 Current guidelines recommend that in AF-patients with ine or more stroke factors (CHA2DS2-VASc score), OAC is recommended. During elective angiography and PCI? 1)Discontinue OAC 5-7 days prior + Bridging heparin 2)Discontinue OAC (5-7 D) + no additional/ Briding heparin 3)Uninterrupted OAC with therapeutic INR level (2.0-3.0) .No additional heparins
  19. 19. Wide variability in Practice on oral anticoagulation therapy pts undergoing coronary stenting M.Valgimigli, EUROPCR, 2013 Tx at discharge in the CRUSADE registry among 1,247 pts with AF
  20. 20. A. Rubboli, EUROPCR, 2013
  21. 21. WOEST: Primary Endpoint: Total number of TIMI bleeding events
  22. 22. WOEST: Secondary Endpoint( Death, MI, TVR, Stroke, ST
  23. 23. Take home message Bleeding is as important as preventing ischaemic complications • Revisit bivalirudin with new protocol • Consider enoxaparin - has less bleeding • Continue OAC prior to PCI or cor.Angio-inr around 2 • OAC And the inopyridine safer than OAC And DAPT

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