Ponencia presentada por el Dr. Raúl Moreno Gómez en el directo online ‘Anticoagulación de cine en el paciente mayor’, realizado el 13 de febrero de 2020 en la Casa del Corazón.
The EMPEROR-Preserved trial evaluated whether empagliflozin reduces cardiovascular death or hospitalization for heart failure in adults with either heart failure with mid-range or preserved ejection fraction. The trial randomized over 5,000 patients to empagliflozin 10 mg daily or placebo, with a median follow up of 26 months. Empagliflozin reduced the primary composite outcome of cardiovascular death or hospitalization for heart failure by 21% compared to placebo, driven mainly by a 29% lower risk of hospitalization for heart failure.
The document reports on a study from the ISCHEMIA trial investigating the impact of complete versus incomplete revascularization on clinical outcomes in patients with stable ischemic heart disease treated with an invasive versus conservative strategy. It finds that among patients treated with an invasive strategy, complete anatomic or functional revascularization was associated with improved outcomes compared to incomplete revascularization. However, after adjustment for covariates, the differences in outcomes between complete and incomplete revascularization were no longer statistically significant.
This document summarizes the results of a post-hoc analysis of the TWILIGHT trial to evaluate the safety and efficacy of ticagrelor monotherapy versus ticagrelor plus aspirin in patients who underwent complex percutaneous coronary intervention (PCI). The analysis found that in patients who underwent complex PCI, ticagrelor monotherapy was associated with a lower risk of clinically relevant bleeding compared to ticagrelor plus aspirin, without increasing the risk of ischemic events. Specifically, ticagrelor monotherapy resulted in a 46% lower risk of BARC type 3 or higher bleeding. There were no significant differences in rates of death, myocardial infarction, or stroke between the two treatment groups in either complex or non-
Coronary Ostial stenting techniques:Current statusPawan Ola
Ostial lesions, located within 3 mm of a vessel origin, pose unique challenges for percutaneous coronary intervention (PCI). Precise stent placement is required to avoid geographic miss and ensure optimal coverage of the lesion. Several techniques have been developed to aid accurate stent placement for ostial lesions, including aorto-free floating wire, stent pull-back, and Szabo/anchor wire methods. The use of these targeted approaches can reduce the risk of additional stenting and reintervention compared to conventional PCI for ostial lesions.
1) Clopidogrel (Plavix) is a drug that inhibits platelet activation and is used to prevent heart attacks and strokes. However, some patients show resistance to its effects.
2) Clopidogrel resistance can be defined biochemically by measuring platelet inhibition or clinically by poor outcomes despite treatment. Potential causes include genetic factors and drug interactions.
3) For patients undergoing stent placement, clopidogrel resistance is associated with higher risks of stent thrombosis and heart attack. Management strategies include higher loading doses, repeated loading doses based on tests of platelet function, and alternative antiplatelet drugs.
The TREAT trial compared ticagrelor to clopidogrel in patients who received fibrinolytic therapy for ST-elevation myocardial infarction (STEMI). The trial aimed to evaluate the safety of ticagrelor in this setting given concerns about bleeding risk. The primary safety outcome was major bleeding at 30 days, with major efficacy outcomes including death from cardiovascular causes, myocardial infarction or stroke. The trial found ticagrelor to be non-inferior to clopidogrel for major bleeding at 30 days. Rates of other bleeding outcomes and major cardiovascular events were also similar between the two treatments.
This document discusses chronic total occlusion (CTO) of coronary arteries. It defines CTO and differentiates it from functional occlusions and pseudo-occlusions. The prevalence of CTO is estimated to be around 15% based on registry data. CTOs present technical challenges for percutaneous coronary intervention (PCI) due to factors like lesion length, calcification, and tortuosity. Proper preparation is important for CTO PCI, including adequate guide support and anticoagulation. Scoring systems can help predict the difficulty of crossing a CTO. Special guidewires and techniques may be needed depending on the lesion characteristics and collateral pathways.
The EMPEROR-Preserved trial evaluated whether empagliflozin reduces cardiovascular death or hospitalization for heart failure in adults with either heart failure with mid-range or preserved ejection fraction. The trial randomized over 5,000 patients to empagliflozin 10 mg daily or placebo, with a median follow up of 26 months. Empagliflozin reduced the primary composite outcome of cardiovascular death or hospitalization for heart failure by 21% compared to placebo, driven mainly by a 29% lower risk of hospitalization for heart failure.
The document reports on a study from the ISCHEMIA trial investigating the impact of complete versus incomplete revascularization on clinical outcomes in patients with stable ischemic heart disease treated with an invasive versus conservative strategy. It finds that among patients treated with an invasive strategy, complete anatomic or functional revascularization was associated with improved outcomes compared to incomplete revascularization. However, after adjustment for covariates, the differences in outcomes between complete and incomplete revascularization were no longer statistically significant.
This document summarizes the results of a post-hoc analysis of the TWILIGHT trial to evaluate the safety and efficacy of ticagrelor monotherapy versus ticagrelor plus aspirin in patients who underwent complex percutaneous coronary intervention (PCI). The analysis found that in patients who underwent complex PCI, ticagrelor monotherapy was associated with a lower risk of clinically relevant bleeding compared to ticagrelor plus aspirin, without increasing the risk of ischemic events. Specifically, ticagrelor monotherapy resulted in a 46% lower risk of BARC type 3 or higher bleeding. There were no significant differences in rates of death, myocardial infarction, or stroke between the two treatment groups in either complex or non-
Coronary Ostial stenting techniques:Current statusPawan Ola
Ostial lesions, located within 3 mm of a vessel origin, pose unique challenges for percutaneous coronary intervention (PCI). Precise stent placement is required to avoid geographic miss and ensure optimal coverage of the lesion. Several techniques have been developed to aid accurate stent placement for ostial lesions, including aorto-free floating wire, stent pull-back, and Szabo/anchor wire methods. The use of these targeted approaches can reduce the risk of additional stenting and reintervention compared to conventional PCI for ostial lesions.
1) Clopidogrel (Plavix) is a drug that inhibits platelet activation and is used to prevent heart attacks and strokes. However, some patients show resistance to its effects.
2) Clopidogrel resistance can be defined biochemically by measuring platelet inhibition or clinically by poor outcomes despite treatment. Potential causes include genetic factors and drug interactions.
3) For patients undergoing stent placement, clopidogrel resistance is associated with higher risks of stent thrombosis and heart attack. Management strategies include higher loading doses, repeated loading doses based on tests of platelet function, and alternative antiplatelet drugs.
The TREAT trial compared ticagrelor to clopidogrel in patients who received fibrinolytic therapy for ST-elevation myocardial infarction (STEMI). The trial aimed to evaluate the safety of ticagrelor in this setting given concerns about bleeding risk. The primary safety outcome was major bleeding at 30 days, with major efficacy outcomes including death from cardiovascular causes, myocardial infarction or stroke. The trial found ticagrelor to be non-inferior to clopidogrel for major bleeding at 30 days. Rates of other bleeding outcomes and major cardiovascular events were also similar between the two treatments.
This document discusses chronic total occlusion (CTO) of coronary arteries. It defines CTO and differentiates it from functional occlusions and pseudo-occlusions. The prevalence of CTO is estimated to be around 15% based on registry data. CTOs present technical challenges for percutaneous coronary intervention (PCI) due to factors like lesion length, calcification, and tortuosity. Proper preparation is important for CTO PCI, including adequate guide support and anticoagulation. Scoring systems can help predict the difficulty of crossing a CTO. Special guidewires and techniques may be needed depending on the lesion characteristics and collateral pathways.
This document discusses various topics related to dual antiplatelet therapy (DAPT) including the optimal duration of DAPT after percutaneous coronary intervention (PCI) and drug-eluting stent (DES) implantation. It notes that the appropriate DAPT duration remains controversial and may differ between patients based on their individual risks of ischemia and bleeding. The document also discusses balancing anti-ischemic efficacy against bleeding risk when using antithrombotic therapies and considers strategies like individualizing DAPT duration based on patient characteristics. Triple antithrombotic therapy combining DAPT and oral anticoagulants for patients with atrial fibrillation is also reviewed.
Ticagrelor in acute myocardial infarctionVasif Mayan
Potential benefits of dual antiplatelet therapy beyond 1 year after an MI has not been studied
Patients with MI are at increased risk of RECURRENT ISCHAEMIC EVENTS
Intensive secondary prevention is theoretically beneficial
Finding an ideal drug with best risk-benefit ratio is a challenge
TICAGRELOR
--- Direct acting
Not a pro-drug; does not require metabolic activation
Rapid onset of inhibitory effect on the P2Y12 receptor
Greater inhibition of platelet aggregation than clopidogrel
--- Reversibly bound
Degree of inhibition reflects plasma concentration
Faster offset of effect than clopidogrel
Functional recovery of circulating platelets within ~48 hours
PLATO trial
PEGASUS TIMI trial
The COURAGE trial randomized 2287 patients with stable coronary artery disease to optimal medical therapy alone or with percutaneous coronary intervention. At a median follow up of 4.6 years, the rates of death or non-fatal myocardial infarction were 19% in the PCI group and 18.5% in the medical therapy group, showing no significant difference. PCI was associated with higher costs and more revascularization procedures compared to medical therapy alone. For patients with stable coronary disease, an initial strategy of optimal medical therapy is reasonable as it is not inferior to routine PCI and is more cost effective.
1) The document discusses antiplatelet therapy for Asian patients with acute coronary syndrome (ACS) who undergo percutaneous coronary intervention (PCI), specifically comparing ticagrelor and clopidogrel.
2) The PLATO trial showed ticagrelor reduced cardiovascular events compared to clopidogrel in ACS patients but increased major bleeding risks. However, the PHILO trial of ticagrelor vs clopidogrel in Asian ACS patients found no difference in cardiovascular outcomes or major bleeding.
3) Guidelines recommend balancing bleeding risks with potential benefits when choosing antiplatelet therapy for Asians, as they may have a different therapeutic window than Caucasians. De-escalating or switching
This document discusses various adjunct devices that are used in percutaneous coronary interventions (PCI). It describes plaque modification devices like cutting balloons and lasers that can facilitate procedural success and reduce restenosis. Cutting balloons make controlled incisions in plaque to enlarge vessels at lower pressures. Lasers precisely remove plaque but are infrequently used due to high cost. Thrombectomy devices like manual aspiration catheters can reduce thrombus burden in acute myocardial infarction to improve perfusion. Embolic protection devices trap debris during stenting of saphenous vein grafts to prevent distal embolization.
The STITCH trial evaluated the effect of CABG plus optimal medical therapy (OMT) versus OMT alone on mortality in patients with left ventricular dysfunction and coronary artery disease. A sub-study examined the role of assessing myocardial viability to identify patients who benefit most from CABG. Of 601 patients who underwent viability testing, 487 had viable myocardium and 114 did not. There was no significant interaction between viability status and treatment assignment on mortality or other outcomes. Assessing viability did not identify patients with differential survival benefit from CABG versus OMT alone.
This document discusses the benefits of high-dose statin therapy for patients with acute coronary syndrome (ACS). It summarizes several studies that found high-dose statin therapy started very early (within 24 hours) for ACS patients was associated with reduced mortality. One study of over 10,000 ACS patients found very early statin therapy reduced 7-day and 30-day mortality. Another study found high-dose atorvastatin improved coronary flow and ST segment resolution in STEMI patients compared to low-dose atorvastatin. The document also notes that statin therapy duration is important, with one study finding risk of further cardiovascular events was lower the longer patients continued high-dose atorvastatin therapy.
Treatment of in-stent restenosis remains challenging. Drug-eluting stents have significantly reduced restenosis rates compared to bare-metal stents but treating drug-eluting stent in-stent restenosis is particularly difficult. Intracoronary imaging can provide insights into underlying causes of in-stent restenosis and guide repeated interventions. Current treatment strategies include balloon angioplasty, cutting/scoring balloons, debulking techniques, brachytherapy, and repeat stenting with drug-eluting stents. However, outcomes remain poorer for drug-eluting stent in-stent restenosis compared to bare-metal stent restenosis.
This document discusses left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation. It provides background on atrial fibrillation and the increased risk of stroke. Left atrial appendage occlusion is recommended for patients with a high stroke risk who have contraindications to oral anticoagulation. The document reviews patient selection criteria and contraindications for left atrial appendage occlusion. It also examines left atrial appendage anatomy, imaging techniques for evaluation, and various closure devices including the Watchman, Amplatzer, and Lariat systems.
- Drug-eluting stents significantly reduced restenosis rates compared to bare-metal stents, but in-stent restenosis still occurs in 5-10% of cases.
- Restenosis can be focal or diffuse and is classified based on its severity and treatment approach. Higher grades of restenosis are associated with poorer outcomes.
- Factors contributing to in-stent restenosis include patient and lesion characteristics, stent design and materials, drug effects, inflammation, neoatherosclerosis, low wall shear stress areas, and potential thrombus formation.
- Earlier and more rapid neoatherosclerosis may occur inside drug-eluting stents compared to bare-metal stents,
The document summarizes a clinical trial that evaluated the angiotensin receptor-neprilysin inhibitor LCZ696 compared to the angiotensin converting enzyme inhibitor enalapril in patients with heart failure with reduced ejection fraction. The trial found that LCZ696 was superior to enalapril in reducing the composite outcome of cardiovascular death or heart failure hospitalization. LCZ696 also reduced rates of all-cause mortality and improved symptoms and physical limitations compared to enalapril. However, LCZ696 was associated with a higher risk of hypotension.
The KDIGO 2022 Clinical Practice Guideline on Diabetes Management in CKD provides recommendations and guidance to help clinicians manage patients with both diabetes and chronic kidney disease. The guideline was developed by an international work group using the GRADE approach. It addresses topics such as comprehensive care, glycemic monitoring and targets, lifestyle interventions, glucose-lowering therapies, and approaches to management. The guideline aims to reduce risks of kidney disease progression and cardiovascular disease for these high-risk patients.
- The SYNTAX trial compared outcomes of percutaneous coronary intervention (PCI) using drug-eluting stents versus coronary artery bypass grafting (CABG) for treating three-vessel or left main coronary artery disease.
- For the primary endpoint of major adverse cardiac and cerebrovascular events at 12 months, CABG was superior to PCI. However, outcomes were similar between treatments for patients with less complex disease as measured by low or intermediate SYNTAX scores.
- For patients with more complex disease and high SYNTAX scores, CABG had significantly fewer primary events than PCI at 12 months.
Clopidogrel is a pro-drug that requires hepatic metabolism to become active. It is a cornerstone of treatment for acute coronary syndrome (ACS) as dual antiplatelet therapy with aspirin. The CURE trial showed clopidogrel plus aspirin reduces cardiovascular events in ACS patients compared to aspirin alone. Later trials like CREDO found clopidogrel reduces events in patients post-percutaneous coronary intervention compared to aspirin. Newer P2Y12 inhibitors like prasugrel and ticagrelor are more effective at preventing ischemia but with increased bleeding risk. De-escalating dual antiplatelet therapy from newer drugs to clopidogrel appears safe and effective.
Cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillators (ICDs) can help optimize heart failure management. CRT improves symptoms, reduces hospitalizations, and increases survival in patients with reduced ejection fraction, left bundle branch block, and wide QRS duration. ICDs prevent sudden cardiac death in high-risk patients with prior heart failure, low ejection fraction, or history of dangerous arrhythmias. New devices use adaptive and multi-point pacing to better resynchronize the left ventricle. Device therapy improves outcomes when guided by clinical evidence and used in appropriate heart failure patients.
Management of AF patients with ACS undergoing PCI.pptxPraveen Nagula
- The AUGUSTUS trial compared apixaban to vitamin K antagonist (VKA) for prevention of thromboembolic events in patients with atrial fibrillation undergoing percutaneous coronary intervention or experiencing acute coronary syndrome.
- Over 4,600 patients were randomized to apixaban 5mg twice daily or adjusted-dose VKA plus a P2Y12 inhibitor with or without aspirin for 6 months.
- The primary outcome was major or clinically relevant non-major bleeding. Apixaban resulted in a 31% relative risk reduction in the primary outcome compared to VKA.
The ENVISAGE-TAVI trial compared edoxaban to warfarin for stroke prevention in patients with atrial fibrillation following transcatheter aortic valve replacement (TAVR). The trial randomized 1426 patients 1:1 to edoxaban 60 mg daily or dose-adjusted warfarin. The primary endpoint was a composite of death, myocardial infarction, ischemic stroke, systemic embolism, valve thrombosis or major bleeding (net adverse clinical events). Edoxaban was found to be noninferior to warfarin for the primary endpoint with a hazard ratio of 0.82 (95% CI 0.65-1.04). Rates of major bleeding were also similar between the groups. The
1) The PIONEER AF-PCI study found that among patients with atrial fibrillation who underwent percutaneous coronary intervention, treatment with rivaroxaban plus either P2Y12 inhibitor monotherapy or dual antiplatelet therapy for one year reduced the risk of clinically significant bleeding compared to standard vitamin K antagonist plus dual antiplatelet therapy, with comparable efficacy results.
2) The EUCLID study found that in patients with peripheral artery disease, ticagrelor was not superior to clopidogrel for reducing cardiovascular events, though ticagrelor was discontinued more often due to side effects like dyspnea.
3) The PRECISION trial demonstrated similar rates of cardiovascular events
This document discusses various topics related to dual antiplatelet therapy (DAPT) including the optimal duration of DAPT after percutaneous coronary intervention (PCI) and drug-eluting stent (DES) implantation. It notes that the appropriate DAPT duration remains controversial and may differ between patients based on their individual risks of ischemia and bleeding. The document also discusses balancing anti-ischemic efficacy against bleeding risk when using antithrombotic therapies and considers strategies like individualizing DAPT duration based on patient characteristics. Triple antithrombotic therapy combining DAPT and oral anticoagulants for patients with atrial fibrillation is also reviewed.
Ticagrelor in acute myocardial infarctionVasif Mayan
Potential benefits of dual antiplatelet therapy beyond 1 year after an MI has not been studied
Patients with MI are at increased risk of RECURRENT ISCHAEMIC EVENTS
Intensive secondary prevention is theoretically beneficial
Finding an ideal drug with best risk-benefit ratio is a challenge
TICAGRELOR
--- Direct acting
Not a pro-drug; does not require metabolic activation
Rapid onset of inhibitory effect on the P2Y12 receptor
Greater inhibition of platelet aggregation than clopidogrel
--- Reversibly bound
Degree of inhibition reflects plasma concentration
Faster offset of effect than clopidogrel
Functional recovery of circulating platelets within ~48 hours
PLATO trial
PEGASUS TIMI trial
The COURAGE trial randomized 2287 patients with stable coronary artery disease to optimal medical therapy alone or with percutaneous coronary intervention. At a median follow up of 4.6 years, the rates of death or non-fatal myocardial infarction were 19% in the PCI group and 18.5% in the medical therapy group, showing no significant difference. PCI was associated with higher costs and more revascularization procedures compared to medical therapy alone. For patients with stable coronary disease, an initial strategy of optimal medical therapy is reasonable as it is not inferior to routine PCI and is more cost effective.
1) The document discusses antiplatelet therapy for Asian patients with acute coronary syndrome (ACS) who undergo percutaneous coronary intervention (PCI), specifically comparing ticagrelor and clopidogrel.
2) The PLATO trial showed ticagrelor reduced cardiovascular events compared to clopidogrel in ACS patients but increased major bleeding risks. However, the PHILO trial of ticagrelor vs clopidogrel in Asian ACS patients found no difference in cardiovascular outcomes or major bleeding.
3) Guidelines recommend balancing bleeding risks with potential benefits when choosing antiplatelet therapy for Asians, as they may have a different therapeutic window than Caucasians. De-escalating or switching
This document discusses various adjunct devices that are used in percutaneous coronary interventions (PCI). It describes plaque modification devices like cutting balloons and lasers that can facilitate procedural success and reduce restenosis. Cutting balloons make controlled incisions in plaque to enlarge vessels at lower pressures. Lasers precisely remove plaque but are infrequently used due to high cost. Thrombectomy devices like manual aspiration catheters can reduce thrombus burden in acute myocardial infarction to improve perfusion. Embolic protection devices trap debris during stenting of saphenous vein grafts to prevent distal embolization.
The STITCH trial evaluated the effect of CABG plus optimal medical therapy (OMT) versus OMT alone on mortality in patients with left ventricular dysfunction and coronary artery disease. A sub-study examined the role of assessing myocardial viability to identify patients who benefit most from CABG. Of 601 patients who underwent viability testing, 487 had viable myocardium and 114 did not. There was no significant interaction between viability status and treatment assignment on mortality or other outcomes. Assessing viability did not identify patients with differential survival benefit from CABG versus OMT alone.
This document discusses the benefits of high-dose statin therapy for patients with acute coronary syndrome (ACS). It summarizes several studies that found high-dose statin therapy started very early (within 24 hours) for ACS patients was associated with reduced mortality. One study of over 10,000 ACS patients found very early statin therapy reduced 7-day and 30-day mortality. Another study found high-dose atorvastatin improved coronary flow and ST segment resolution in STEMI patients compared to low-dose atorvastatin. The document also notes that statin therapy duration is important, with one study finding risk of further cardiovascular events was lower the longer patients continued high-dose atorvastatin therapy.
Treatment of in-stent restenosis remains challenging. Drug-eluting stents have significantly reduced restenosis rates compared to bare-metal stents but treating drug-eluting stent in-stent restenosis is particularly difficult. Intracoronary imaging can provide insights into underlying causes of in-stent restenosis and guide repeated interventions. Current treatment strategies include balloon angioplasty, cutting/scoring balloons, debulking techniques, brachytherapy, and repeat stenting with drug-eluting stents. However, outcomes remain poorer for drug-eluting stent in-stent restenosis compared to bare-metal stent restenosis.
This document discusses left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation. It provides background on atrial fibrillation and the increased risk of stroke. Left atrial appendage occlusion is recommended for patients with a high stroke risk who have contraindications to oral anticoagulation. The document reviews patient selection criteria and contraindications for left atrial appendage occlusion. It also examines left atrial appendage anatomy, imaging techniques for evaluation, and various closure devices including the Watchman, Amplatzer, and Lariat systems.
- Drug-eluting stents significantly reduced restenosis rates compared to bare-metal stents, but in-stent restenosis still occurs in 5-10% of cases.
- Restenosis can be focal or diffuse and is classified based on its severity and treatment approach. Higher grades of restenosis are associated with poorer outcomes.
- Factors contributing to in-stent restenosis include patient and lesion characteristics, stent design and materials, drug effects, inflammation, neoatherosclerosis, low wall shear stress areas, and potential thrombus formation.
- Earlier and more rapid neoatherosclerosis may occur inside drug-eluting stents compared to bare-metal stents,
The document summarizes a clinical trial that evaluated the angiotensin receptor-neprilysin inhibitor LCZ696 compared to the angiotensin converting enzyme inhibitor enalapril in patients with heart failure with reduced ejection fraction. The trial found that LCZ696 was superior to enalapril in reducing the composite outcome of cardiovascular death or heart failure hospitalization. LCZ696 also reduced rates of all-cause mortality and improved symptoms and physical limitations compared to enalapril. However, LCZ696 was associated with a higher risk of hypotension.
The KDIGO 2022 Clinical Practice Guideline on Diabetes Management in CKD provides recommendations and guidance to help clinicians manage patients with both diabetes and chronic kidney disease. The guideline was developed by an international work group using the GRADE approach. It addresses topics such as comprehensive care, glycemic monitoring and targets, lifestyle interventions, glucose-lowering therapies, and approaches to management. The guideline aims to reduce risks of kidney disease progression and cardiovascular disease for these high-risk patients.
- The SYNTAX trial compared outcomes of percutaneous coronary intervention (PCI) using drug-eluting stents versus coronary artery bypass grafting (CABG) for treating three-vessel or left main coronary artery disease.
- For the primary endpoint of major adverse cardiac and cerebrovascular events at 12 months, CABG was superior to PCI. However, outcomes were similar between treatments for patients with less complex disease as measured by low or intermediate SYNTAX scores.
- For patients with more complex disease and high SYNTAX scores, CABG had significantly fewer primary events than PCI at 12 months.
Clopidogrel is a pro-drug that requires hepatic metabolism to become active. It is a cornerstone of treatment for acute coronary syndrome (ACS) as dual antiplatelet therapy with aspirin. The CURE trial showed clopidogrel plus aspirin reduces cardiovascular events in ACS patients compared to aspirin alone. Later trials like CREDO found clopidogrel reduces events in patients post-percutaneous coronary intervention compared to aspirin. Newer P2Y12 inhibitors like prasugrel and ticagrelor are more effective at preventing ischemia but with increased bleeding risk. De-escalating dual antiplatelet therapy from newer drugs to clopidogrel appears safe and effective.
Cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillators (ICDs) can help optimize heart failure management. CRT improves symptoms, reduces hospitalizations, and increases survival in patients with reduced ejection fraction, left bundle branch block, and wide QRS duration. ICDs prevent sudden cardiac death in high-risk patients with prior heart failure, low ejection fraction, or history of dangerous arrhythmias. New devices use adaptive and multi-point pacing to better resynchronize the left ventricle. Device therapy improves outcomes when guided by clinical evidence and used in appropriate heart failure patients.
Management of AF patients with ACS undergoing PCI.pptxPraveen Nagula
- The AUGUSTUS trial compared apixaban to vitamin K antagonist (VKA) for prevention of thromboembolic events in patients with atrial fibrillation undergoing percutaneous coronary intervention or experiencing acute coronary syndrome.
- Over 4,600 patients were randomized to apixaban 5mg twice daily or adjusted-dose VKA plus a P2Y12 inhibitor with or without aspirin for 6 months.
- The primary outcome was major or clinically relevant non-major bleeding. Apixaban resulted in a 31% relative risk reduction in the primary outcome compared to VKA.
The ENVISAGE-TAVI trial compared edoxaban to warfarin for stroke prevention in patients with atrial fibrillation following transcatheter aortic valve replacement (TAVR). The trial randomized 1426 patients 1:1 to edoxaban 60 mg daily or dose-adjusted warfarin. The primary endpoint was a composite of death, myocardial infarction, ischemic stroke, systemic embolism, valve thrombosis or major bleeding (net adverse clinical events). Edoxaban was found to be noninferior to warfarin for the primary endpoint with a hazard ratio of 0.82 (95% CI 0.65-1.04). Rates of major bleeding were also similar between the groups. The
1) The PIONEER AF-PCI study found that among patients with atrial fibrillation who underwent percutaneous coronary intervention, treatment with rivaroxaban plus either P2Y12 inhibitor monotherapy or dual antiplatelet therapy for one year reduced the risk of clinically significant bleeding compared to standard vitamin K antagonist plus dual antiplatelet therapy, with comparable efficacy results.
2) The EUCLID study found that in patients with peripheral artery disease, ticagrelor was not superior to clopidogrel for reducing cardiovascular events, though ticagrelor was discontinued more often due to side effects like dyspnea.
3) The PRECISION trial demonstrated similar rates of cardiovascular events
Overview of Non Vitamin K oral anticoagulantsNeeraj Varyani
Dabigatran, rivaroxaban, and apixaban are novel oral anticoagulants (NOACs) that are alternatives to warfarin for preventing strokes in atrial fibrillation and treating deep vein thrombosis. Large clinical trials found these NOACs to be as effective as warfarin with less risk of bleeding. Dabigatran 150mg twice daily was more effective than warfarin at preventing strokes while 110mg twice daily had similar efficacy but lower bleeding. Rivaroxaban and apixaban were noninferior to warfarin with similar or lower risks of bleeding. Edoxaban is another NOAC that was found noninferior to warfarin in
1) The document discusses atrial fibrillation (AF), its increasing prevalence, and its association with increased risk of stroke.
2) It reviews stroke risk assessment tools like CHADS2 and CHA2DS2-VASc scores and guidelines for stroke prevention in AF patients using anticoagulation or the newer oral anticoagulants (NOACs).
3) It also discusses left atrial appendage closure with the Watchman device as an alternative for stroke prevention in patients who cannot tolerate long-term anticoagulation. The Watchman trials demonstrated the device's safety and efficacy in reducing stroke risk comparable to warfarin.
This document summarizes information on new oral anticoagulants (NOACs) as of March 2014. It discusses pharmaceutical companies that produce NOACs, clinical trials comparing NOACs to warfarin for stroke prevention in atrial fibrillation and treatment of venous thromboembolism, and trials examining NOACs for thromboprophylaxis. The document also notes that 24.7-25.9% of patients in the RE-LY trial of dabigatran had oral anticoagulation interrupted for surgery or procedures, with the most common being pacemaker insertion, dental work, diagnostic tests, cataract removal, and colonoscopy.
This document summarizes several studies on newer oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation. It finds that dabigatran 150mg twice daily, apixaban 5mg twice daily, and edoxaban 60mg once daily were superior or non-inferior to warfarin in reducing strokes and systemic embolisms while reducing major bleeding events. Rivaroxaban was found to be non-inferior to warfarin with similar rates of ischemic strokes, mortality, and major bleeding, but increased gastrointestinal bleeding. Idarucizumab and andexanet alfa show promise as reversal agents for dabigatran and factor Xa inhibitors respectively.
Novedades en el manejo del paciente con FA: actualización tras AHA 2016
22/11/2016 19:30h Casa del Corazón, Madrid
http://manejofa.secardiologia.es
#manejoFA
Pacientes con FA que sufren un SCA y son sometidos a intervención coronaria percutánea. Guías y preguntas abiertas
Dr. Antonio Fernández Ortiz, Hospital Universitario Clínico San Carlos (Madrid)
4 dan atar - anticoagulation af pci - what do trials saywebevo5
Professor Dan Atar presented on anticoagulation for atrial fibrillation and percutaneous coronary intervention based on recent trial results. The WOEST trial found that dual therapy with a vitamin K antagonist (VKA) and clopidogrel reduced bleeding compared to triple therapy with a VKA, aspirin, and clopidogrel, with a potential mortality benefit. The PIONEER AF-PCI trials found that rivaroxaban dual or triple therapy was associated with significantly less bleeding than VKA triple therapy, with comparable efficacy. The RE-LY-DUAL PCI study found dabigatran dual therapy significantly reduced bleeding compared to warfarin triple therapy. Guidelines recommend balancing the risks of bleeding from
This document provides an outline on the topic of novel oral anticoagulants (NOACs) including:
1) An introduction to NOACs and their advantages over vitamin K antagonists.
2) Details on the properties, indications, dosing, and trial results of specific NOACs including Dabigatran, Rivaroxaban, Apixaban, and Edoxaban.
3) Guidance on switching between anticoagulant regimens, dealing with dosing errors, and follow-up of patients on NOACs.
The study evaluated the efficacy and safety of rivaroxaban compared to vitamin K antagonists for stroke prevention in patients with rheumatic heart disease-associated atrial fibrillation (RHD-AF). Over 4565 patients from 24 countries were randomized to receive either rivaroxaban 20 mg daily or a vitamin K antagonist such as warfarin, with a mean follow up of 3.1 years. The primary outcome occurred in 560 patients (8.21% per year) in the rivaroxaban group and 446 patients (6.49% per year) in the vitamin K antagonist group, showing rivaroxaban to be less effective with a hazard ratio of 1.25. There were no significant
Lo mejor del ACC 2015 (San Diego)
Miércoles, 18/3/15 De 14:00 a 15:30
Casa del Corazón. Sociedad Española de Cardiología.
http://acc15.secardiologia.es/
Arritmias/Insuficiencia cardiaca
Dr. Romàn Freixa Pamias
Servicio de Cardiología. Hospital Moisés Broggi, Barcelona
This document discusses several studies related to atrial fibrillation and anticoagulation therapy:
1. A study of over 13,000 AF patients found higher baseline BNP levels were associated with increased risk of AF progression and major adverse cardiovascular events.
2. A direct comparison of dabigatran, rivaroxaban, and apixaban found apixaban and rivaroxaban had comparable safety and effectiveness to dabigatran in real-world practice, though major bleeding occurred more frequently with apixaban and rivaroxaban.
3. A study of NOAC safety in obese patients undergoing electrical cardioversion found no incidents of stroke, suggesting NOACs may be safe
This document provides an outline and overview of newer oral anticoagulants (NOACs). It discusses the types of NOACs including dabigatran, rivaroxaban, and apixaban. It describes the properties, indications, dosing, and results of clinical trials comparing each NOAC to warfarin for preventing strokes in atrial fibrillation and for treating deep vein thrombosis. The document concludes that NOACs have advantages over warfarin such as fewer drug interactions and no need for regular monitoring, though they have slightly higher risks of gastrointestinal bleeding.
The document discusses newer oral anticoagulants (NOACs) that are alternatives to vitamin K antagonists for treating and preventing blood clots. It describes several NOACs including dabigatran, rivaroxaban, apixaban, and edoxaban. For each drug, it provides information on indications, pharmacokinetics, dosing regimens, clinical trials results, and safety compared to warfarin. The document concludes that NOACs are as effective as warfarin with less monitoring requirements but may have a higher risk of gastrointestinal bleeding.
This document discusses several landmark clinical trials that tested the effectiveness of ACE inhibitors and ARBs in treating myocardial infarction and heart failure. The SAVE trial showed that captopril reduced mortality after MI in patients with reduced ejection fraction. The AIRE and TRACE trials found that ramipril and trandolapril respectively reduced mortality in post-MI patients with heart failure or left ventricular dysfunction. The GISSI-3 trial showed lisinopril improved outcomes after acute MI. Finally, the VALIANT trial found valsartan was as effective as captopril in reducing mortality in high-risk post-MI patients.
Oral anticoagulation with vitamin K antagonists or non-vitamin K antagonist oral anticoagulants (NOACs) is the standard of care for reducing thromboembolic risk in patients with atrial fibrillation (AF). Warfarin is effective but has limitations including a narrow therapeutic window requiring frequent monitoring and dose adjustments. NOACs have advantages over warfarin such as rapid onset, fewer drug interactions and no requirement for routine monitoring. Apixaban and edoxaban have been shown to have the lowest risk of gastrointestinal bleeding compared to other NOACs based on data from pivotal clinical trials. Dosing of NOACs requires adjustment based on renal function and bleeding risk.
The document summarizes key findings from the ADVANCE trial, the largest clinical trial in type 2 diabetes. The ADVANCE trial involved over 11,000 patients across 20 countries and found that intensive glycemic control using gliclazide modified release provided significant reductions in microvascular and macrovascular complications compared to standard care, including a 10% reduction in combined microvascular and macrovascular events. Intensive control with gliclazide MR also resulted in unique renal protection and the lowest rates of hypoglycemia compared to other major trials.
Dr. Raphael Rosso — The Role of Catheter-Based Closure of the Left Atrial App...Pavel Fedotov
This document summarizes data from studies on left atrial appendage closure for stroke prevention in atrial fibrillation patients. It finds that around 15-20% of strokes are due to atrial fibrillation, with around 90% of these being cardioembolic and forming in the left atrial appendage. The Watchman device was found to be non-inferior to warfarin for stroke prevention over 2.3 years of follow up. Complication rates with the device were between 2-5% and decreased with operator experience. The device provides an alternative to oral anticoagulation for stroke prevention in atrial fibrillation patients unsuitable for warfarin.
Similar to Braveheart. NOAC in AF patients after coronary stenting (20)
La Sociedad Española de Cardiología (SEC) es una organización científica sin ánimo de lucro con la misión de reducir el impacto adverso de las enfermedades cardiovasculares y promover una mejor salud cardiovascular en la ciudadanía.
Ponencia presentada por la Dra. Marisol Bravo Amaro en el CardioTV Live ‘Debatiendo estrategias actuales para la reducción de eventos CV tras síndrome coronario agudo reciente’, realizado el 21 de mayo de 2024 en la Casa del Corazón
Ponencia presentada por el Dr. Armando Oterino Manzanas en el CardioTV Live ‘Debatiendo estrategias actuales para la reducción de eventos CV tras síndrome coronario agudo reciente’, realizado el 21 de mayo de 2024 en la Casa del Corazón
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Ponencia presentada por los Dres. M.ª Dolores Mesa Rubio, Javier Mora Robles, Margarita Reina Sánchez, M.ª José Castillo Moraga y José Luis Bianchi Llave en el CardioTV Focus, publicado el 25 de abril de 2024 en la Casa del Corazón (Madrid).
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
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These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
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Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
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This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
Braveheart. NOAC in AF patients after coronary stenting
1. NOAC in AF patients after coronary stenting
Dr. Raúl Moreno
Hospital La Paz - Madrid, Spain
BRAVEHEART
Fotoretiradadelapelícula“Braveheart”utilizadaparafineseducativos
segúnelart32delaLPI.
2. • 5-7% patients undergoing PCI have indication for oral
anticoagulation due to AF.
• These patients are at high risk of both thrombotic and bleeding
events.
• Treatment: wide variation in clinical practice.
• Two separate aspects of anti-thrombotic treatment:
– Double versus triple therapy.
– NOAC vs vKA.
HOW IMPORTANT IS THIS PROBLEM
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
3. IMPACT OF POST-DISCHARGE BLEEDING AFTER PCI
(ADAPT-DES STUDY)
Impact of post-discharge bleeding vs MI on mortality
8583 patients treated with ≥ 1 DES prospectively followed-up in 10-15 hospitals.
Platelet reactivity evaluated using VerifyNow showed increased risk of events with high PRU.
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
4. BRAVEHEART
NOAC in AF patients after coronary stenting
Dr. Raúl Moreno
Hospital La Paz - Madrid, Spain
Fotoretiradadelapelícula“Braveheart”utilizadaparafineseducativos
segúnelart32delaLPI.
5. ALL OPTIONS CAN BE GOOD, BAD, AND UGLY AT THE SAME
TIME
DAPT Anticoagulation
Prevention of stent
thrombosis &
reinfarction
Prevention of stroke
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
6. DUAL VERSUS TRIPLE THERAPY IN POST-PCI PATIENTS
WITH AF
11,480 patients with AF and
MI or post-PCI (2000-2009)
in Denmark.
Bleeding events accordingly
to the type of anti-thrombotic
therapy.
Triple therapy: the problem of bleeding
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
7. • 583 patients with indications for OAC undergoing PCI (98% stent, 2/3 DES).
• Randomization to doublé (clopi+VKA) vs triple (ASA+Clopi+VKA) therapy.
DOUBLE VERSUS TRIPLE ANTI-PLATELET THERAPY: WOEST
TRIAL
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
8. DOAC VERSUS VKA: THE PUZZLE HAS BEEN COMPLETED
Rivaroxaban
(PIONEER)
Apixaban
(AUGUSTUS)
Dabigatran
(RE-DUAL)
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
9. Significantly lower rates of ISTH major bleeding or CRNMBE with
dabigatran dual therapyProbabilityofevent(%)
0
0 90 180 270 360 450 540 630 720
Time to first event (days)
40
35
30
25
20
15
10
5
Warfarin
triple therapy
Dabigatran 110 mg
dual therapy
HR: 0.52 (95% CI: 0.42–0.63)
Non-inferiority P<0.001
P<0.001
0 90 180 270 360 450 540 630 720
Time to first event (days)
40
35
30
25
20
15
10
5
0
Dabigatran 150 mg
dual therapy
Warfarin
triple therapy
HR: 0.72 (95% CI: 0.58–0.88)
Non-inferiority P<0.001
P=0.002
2,725 NVAF patients post-CS: warfarin+ASA vs Dabigatran 110 mg BID vs 150 mg BID (all P2Y12 inhibitor).
Primary end point: major or clinically relevant nonmajor bleeding event.
RE-DUAL PCI trial
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
10. No significant differences in efficacy end-points among 3 groups
Composite efficacy end point:
Death, thromboembolic events (MI, stroke, or systemic embolism), or unplanned revascularization.
Cannon et al. N Engl J Med. 2017 Oct 19;377(16):1513-1524.
RE-DUAL PCI trial
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
11. PIONEER-AF trial
2,124 NVAF patients undergoing CS
Group 1: Riva 15 mg + P2Y12
Group 2: Riva 2.5 mg b.i.d. + DAPT followed by Riva 15 mg + P2Y12
Group 3: VKA + DAPT
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
12. My concern with low-dose NOAC: stent thrombosis (trials
unpowered)
RE-DUAL PCI PIONEER AF
≈ 11% of patients
included had
STEMI
≈ 12% of patients
included had
STEMI
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
13. AUGUSTUS trial
ACS PCI
37.3%23.9% 38.8%
76.1%61.2%
• 4,614 patients with AF after ACS and/or PCI.
• 6-month follow-up (!)
2x2 randomization
• Apixaban (standard dose) vs VKA.
• ASA 81 mg/d vs placebo
(in association with any P2Y12 inhibitor ≥ 6
mo).
Primary end-point: major or clinically relevant bleeding through 6 months.
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
14. 10.5
%
14.7%
9.0%
16.1%
Major or CRNMB: Apixaban vs VKA. Major or CRNMB: ASA vs placebo.
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
AUGUSTUS trial
15. ENTRUST-AF
• 1,506 patients with AF after PCI-stent.
• Randomization (1:1 design) to: Edoxaban + P2Y12 inhibitor or vKA + ASA 100 mg/d + P2Y12 inhibitor.
• Primary end-point: major or clinically relevant non-major bleeding at 12 months.
17.0% (20.7% annualized)
20.0% (25.6% annualised)
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
16. Figure S6. Kaplan-Meier curve for the main efficacy endpoint, ITT analysis
0·10
0·09
0·08
0·07
0·06
0·05
0·04
0·03
0·02
0·01
0·00
0 30 60 90 120 150 180 210 240 270 300 330 360
Days from randomisation
EDOXABAN
Number at risk:
751 719 705 695 685 679 670 664 657 652 643 639 575
VKA 755 718 700 690 678 667 661 657 653 646 640 635 575
Edoxaban VKA
Number of events:
Edoxaban: 49/751
VKA: 46/755
HR (95% CI): 1·06 (0·71; 1·69)
Cumulativeincidenceinoutcomes
Main efficacy outcome
(CV death, stroke, systemic embolic events, MI, and definite stent thrombosis)
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
ENTRUST-AF
17. Timing and bleedings
Hypothesis: investigators were concerned
about bleeding risk with VKA and
undertreated these patients
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
ENTRUST-AF
18. 4,510 out of 21,105 patients (21.4%) had previous CAD.
4,5
3,2
3,6
2,5
Prior CAD No prior CAD
VKA Edoxaban 60
Major bleeding (annualized rate).
Putting into context the ENTRUST: CAD patients in the ENGAGE
ARR: 0.9%
RRR: 20%
ARR: 0.7%
RRR: 22%
1,2 1,2
0,7 0,6
Prior CAD No prior CAD
VKA Edoxaban 60
Fatal or life-threatening bleeding
ARR: 0.5%
RRR: 42%
ARR: 0.6%
RRR: 50%
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
19. 4,510 out of 21,105 patients (21.4%) had previous CAD.
5,4
3,2
4,4
2,6
Prior revasc No prior revasc
VKA Edoxaban 60
Major bleeding (annualized rate).
ARR: 1,0%
RRR: 19%
ARR: 0.6%
RRR: 19%
1,4
1,1
0,9
0,6
Prior revasc No prior revasc
VKA Edoxaban 60
Fatal or life-threatening bleeding
ARR: 0.5%
RRR: 36%
ARR: 0.5%
RRR: 45%
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
Putting into context the ENTRUST: CAD patients in the ENGAGE
20. Putting into context the ENTRUST: concomitant use of SAPT
in the ENGAGE
NOAC in AF patients after coronary stenting Dr. Raúl Moreno
22. CONCLUSIONS
• With the ENTRUST trial, the puzzle of NOAC in patients with AF and PCI-
stent is completed.
• In ENTRUST, edoxaban was not inferior to VKA in terms of bleeding
complications, with similar rate of cardiac events.
• The risk reduction in bleeding, although not statistically significant, was
consistent with the benefit observed in other edoxaban trials.
• Edoxaban is now an alternative to other NOAC in patients treated with
PCI-stent and AF.
NOAC in AF patients after coronary stenting Dr. Raúl Moreno