This document summarizes several studies presented at cardiology conferences in 2014 regarding the treatment of acute coronary syndrome (ACS). A key study found that bivalirudin was superior to heparin for patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI), reducing major adverse cardiac events (MACE) but not increasing bleeding risks. Another study found that administering ticagrelor before hospital arrival led to better outcomes for STEMI patients compared to in-hospital administration. A trial presented found no significant difference in MACE between clopidogrel and prasugrel for ACS, though prasugrel reduced stent thrombosis. Finally, a trial showed reduced MACE

1. Que
retenir
de
l’ACC
2014,
l’AHA
2014,
l’ESC
2014
et
le
TCT
2014
?
F
Beygui

2. Bivalirudine
supérieur
à
l’héparine
dans
le
STEMI?
Heat
trial
ACC
2014;
Lancet
2014

3. How Effective are
Antithrombotic Therapies in PPCI
Dr Adeel Shahzad
Dr Rod Stables (PI)
Liverpool Heart and Chest Hospital
Liverpool, UK

4. Assigned
to
Heparin
914
Included
in
analysis
907
915
Assigned
to
Bivalirudin
905
Included
in
analysis
Consent
not
available
in
surviving
paMents
Consent
not
available
in
7
10
surviving
paMents
Received
allocated
Rx
900
Received
no
study
drug
14
Treatment
cross-­‐over
0
LMWH
pre-­‐procedure
3
907
Received
allocated
Rx
7
Received
no
study
drug
1
Treatment
cross-­‐over
4
LMWH
pre-­‐procedure

5. CharacterisMc
Bivalirudin
(%)
Heparin
(%)
P2Y12
use
-­‐
Any
99.6
99.5
-­‐
Clopidogrel
11.8
10.0
-­‐
Prasugrel
27.3
27.6
-­‐
Ticagrelor
61.2
62.7
GPI
use
13.5
15.5
Radial
arterial
access
80.3
82.0
PCI
performed
83.0
81.6

6. Bivalirudin
Heparin
n
%
%
n
MACE
79
8.7
%
v
5.7
%
52
Absolute
risk
increase
=
3.0%
(95%
CI
0.6,
5.4)
RelaMve
risk
=
1.52
(95%
CI
1.1
–
2.1)
P=0.01

7. Bivalirudin
Heparin
n
%
%
n
Death
46
5.1
%
v
4.3
%
39
CVA
15
1.6%
v
1.2%
11
ReinfarcMon
24
2.7%
v
0.9%
8
TLR
24
2.7%
v
0.7%
6
Any
MACE
79
8.7
%
v
5.7
%
52

8. ARC
definite
or
probable
stent
thrombosis
events
Bivalirudin
Heparin
n
%
%
n
All
Events
24
3.4
%
v
0.9
%
6
RelaMve
risk
=
3.91
(95%
CI
1.6
-­‐
9.5)
P=0.001

9. Major
Bleed
BARC
grade
3-­‐5
Minor
Bleed
BARC
grade
2
Bivalirudin
Heparin
n
%
%
n
Minor
Bleed
83
9.2
%
v
10.8
%
98
Major
or
Minor
113
12.5
%
v
13.5
%
122
Minor
Bleed
P=0.25
Major
or
Minor
P=0.54

10. Ticagrelor
en
pré-­‐hospitalier
versus
intra-­‐hospitalier
ATLANTIC
trial
ESC
2014;
NEJM
2014

11. Study
popula+on
and
design

12. Median
+mes
to
pre-­‐
and
in-­‐hospital
steps

13. 1st
Co-­‐primary
endpoint
No
ST-­‐segment
resolu+on
(≥70%)

14. 2nd
Co-­‐primary
endpoint
No
TIMI
3
flow
in
infarct-­‐related
artery

15. Major
adverse
CV
events
up
to
30
days

16. Non-­‐CABG-­‐related
bleeding
events
(PLATO
defini+ons)
-­‐
Safety
popula+on

17. Definite
stent
thrombosis
up
to
10
days

18. Absence
of
ST-­‐segment
resolu+on
by
pa+ent
characteris+cs

19. Prasugrel
TRANLATE
ACS
trial,
TCT
2014

20. TReatment with ADP receptor iNhibitorS:
Longitudinal Assessment of Treatment patterns
and Events after Acute Coronary Syndrome
TCT 2014 First Report Investigation
presented on behalf of the TRANSLATE-ACS Investigators

21. ADP Receptor Inhibitor Selection
Ticlopidine Ticagrelor
Clopidogrel
n=8,846
(72.3%)
Prasugrel
n=3,123
(25.5%)
Current analysis will
focus on 11,969 patients
treated initially with
clopidogrel or prasugrel
n=258 (2.1%)

22. Unadjusted MACE
Cumulative Incidence (%)
As Treated Intention to Treat
Cumulative Incidence (%)
Clopidogrel Clopidogrel
Prasugrel Prasugrel
13.1% vs. 17.1%
p<0.0001
13.5% vs. 17.3%
p<0.0001
MACE = death, MI, stroke, or unplanned revascularization

23. Adjusted MACE
Adj. HR 95% CI P
Primary Analysis
IPW (as treated) 1.03 0.92 – 1.16 0.59
Secondary Analyses
IPW (ITT) 1.00 0.91 – 1.11 0.95
Propensity-matched (as treated) 1.02 0.90 – 1.14 0.81
Propensity-matched (ITT) 1.03 0.93 – 1.14 0.57
Trimmed population (as treated) 0.89 0.76 – 1.05 0.18
Trimmed population (ITT) 0.91 0.79 – 1.06 0.23
HR = hazard ratio; CI = confidence interval
IPW = inverse probability weighting; ITT = intention-to-treat

24. Stent Thrombosis
Cumulative Incidence (%)
As Treated Intention to Treat
0.97% vs. 1.24%, p=0.11
Adj. HR 0.54 (0.33-0.89), p=0.02
0.98% vs. 1.33%, p=0.12
Adj. HR 0.63 (0.42-0.97), p=0.04
Cumulative Incidence (%)
Clopidogrel Clopidogrel
Prasugrel Prasugrel
Stent thrombosis = ARC definite stent thrombosis

25. Adjusted Bleeding
Adj. HR 95% CI P
Primary Analysis
IPW (as treated) 1.30 1.04 – 1.63 0.02
Secondary Analyses
IPW (ITT) 1.30 1.07 – 1.59 0.01
Propensity-matched (as treated) 1.12 0.86 – 1.47 0.41
Propensity-matched (ITT) 1.10 0.88 – 1.37 0.43
Trimmed population (as treated) 0.94 0.64 – 1.36 0.73
Trimmed population (ITT) 0.83 0.58 – 1.18 0.29
HR = hazard ratio; CI = confidence interval
IPW = inverse probability weighting; ITT = intention-to-treat

26. Multi-­‐vessel
Disease
in
the
setting
of
ACS
Ø
30-­‐40%
in
the
seTng
of
STEMI
Muller
DW,
et
al
Multivessel
coronary
artery
disease:
a
key
predictor
of
short-­‐term
prognosis
after
reperfusion
therapy
for
acute
myocardial
infarction.
Thrombolysis
and
Angioplasty
in
Myocardial
Infarction
(TAMI)
Study
Group.
Am
Heart
J
1991;121:1042-­‐9
Toma
M,,
et
al.
Non-­‐culprit
coronary
artery
percutaneous
coronary
intervention
during
acute
ST-­‐segment
elevation
myocardial
infarction:
insights
from
the
APEX-­‐AMI
trial.
European
Heart
Journal
2010;31:1701-­‐7
Ø
44-­‐60%
in
the
seTng
of
NSTEMI
Effects
of
tissue
plasminogen
activator
and
a
comparison
of
early
invasive
and
conservative
strategies
in
unstable
angina
and
non-­‐
Q-­‐wave
myocardial
infarction.
Results
of
the
TIMI
IIIB
Trial.
Thrombolysis
in
Myocardial
Ischemia.
Circulation
1994;89:1545–1556.
Invasive
compared
with
non-­‐invasive
treatment
in
unstable
coronary-­‐artery
disease:
FRISC
II
prospective
randomised
multicentre
study.
FRagmin
and
Fast
Revascularisation
during
InStability
in
Coronary
artery
disease
Investigators.
Lancet
1999;354:708–715.

27. ATL:
revasculariser
l’artère
responsable
ou
toutes
les
artères
dans
le
STEMI
CvLPRIT
trial
ESC
2014

28. Footer
Text
28
Variable
IRA
only
(N=146)
Complete
Revascularisation
(N=150)
P
value
ASA
plus
Clopidogrel
(%)
Ticagrelor
(%)
Prasugrel
(%)
Warfarin
(%)
131/135
(97.0)
54/138
(39.1)
18/135
(13.3)
64/138
(46.4)
2/138
(1.5)
141/142
(99.3)
59/144
(41.0)
19/144
(13.2)
58/144
(40.3)
1/147
(0.7)
0.16
0.75
0.97
0.30
0.61
GPI
(%)
44/139
(31.7)
46/145
(31.7)
0.99
Bivalirudin
(%)
65/128
(50.8)
79/139
(56.8)
0.32
TIMI
0/1
on
arrival
(%)
118/140
(84.3)
120/147
(81.6)
0.55
Thrombus
aspiration
cath
%
105/140
(75.0)
93/145
(64.1)
0.047
DES
(%)
127/140
(90.7)
141/147
(95.9)
0.08
No.
DES
stents/patient
1
(
1,
2)
3
(2,
4)
<
0.0001
Total
Procedure
time
(mins)
41
(30,
55.5)
55
(38,
74)
<
0.0001
Total
contrast
used
(mls)
190
(150,
250)
250
(190,
330)
<
0.0001

29. 29
Results
1:
Percent
MACE
at
12
months
The
primary
endpoint
composite
of
total
mortality,
recurrent
MI,
heart
failure
and
ischaemia-­‐driven
revascularisaMon
at
12
months
IRA
Only
Complete
Revascularisation

30. Variable
IRA
only
(N=146)
Complete
Revascularisation
(N=150)
HR
(95%
CI)
P
value
Time
to
First
Event
MACE
N=
(%)
31
(21.2)
15
(10.0)
0.45
(0.24,
0.84)
0.009
Components
N=(%)
All-­‐cause
mortality
6
(4.1)
2
(1.3)
0.32
(0.06,
1.60)
0.14
Recurrent
MI
4
(2.7)
2
(1.3)
0.48
(0.09,
2.62)
0.39
Heart
failure
9
(6.2)
4
(2.7)
0.43
(0.13,
1.39)
0.14
Repeat
Revascularisation
12
(8.2)
7
(4.7)
0.55
(0.22,
1.39)
0.2
Total
number
of
events
reported
N=
(%)
All-­‐cause
mortality
10
(6.9)
4
(2.7)
0.38
(0.12,
1.20)
0.09
Recurrent
MI
4
(2.7)
2
(1.3)
0.47
(0.09,
2.59)
0.38
Heart
Failure
10
(6.9)
5
(3.3)
0.47
(0.16,
1.38)
0.16
Repeat
Revascularisation
16
(11.0)
8
(5.3)
0.46
(0.20,
1.08)
0.07
Safety
N=
(%)
CV
mortality
7
(4.8)
2
(1.3)
0.27
(0.06,
1.32)
0.11
Stroke
2
(1.4)
2
(1.3)
0.95
(0.13,
6.77)
0.96
Major
Bleed
7
(4.8)
4
(2.7)
0.55
(0.16,
1.87)
0.34
CIN
2(1.4)
2
(1.4)
0.94
(013,6.75)
0.95

31. Study
ID
DiMario 2004
Politi 2010
Wald 2013
Gershlick 2014
Overall (I-squared = 0.0%, p = 0.756)
OR (95% CI)
0.49 (0.15, 1.63)
0.27 (0.15, 0.50)
0.33 (0.19, 0.57)
0.41 (0.21, 0.80)
0.34 (0.24, 0.47)
%
Weight
5.75
32.29
39.16
22.80
100.00
MACE
Favours Mul.t1i-vessel PCI 1 Favours Culp1r0it-only PCI
Study
ID
DiMario 2004
Politi 2010
Wald 2013
Gershlick 2014
Overall (I-squared = 0.0%, p = 0.745)
OR (95% CI)
1.02 (0.04, 26.19)
0.46 (0.19, 1.09)
0.73 (0.34, 1.57)
0.37 (0.11, 1.22)
0.55 (0.33, 0.91)
%
Weight
1.79
36.05
37.77
24.39
100.00
Mortality
.1 1 10 Favours Multi-vessel PCI Favours Culprit-only PCI
05/12/14
Footer
Text
31

32. ATL:
revasculariser
l’artère
responsable
ou
toutes
les
artères
dans
le
NSTEMI?
SMILE
trial
TCT
2014

33. rino.sardella@uniroma1.it
SMILE
TRIAL
Therapy
SINGLE
Staged
(tot.
=
253)
MULTI
Staged
(tot.
=
247)
p
value
Thienopyridines
pre-­‐randomiza+on
Clopidogrel
75
mg
Clopidogrel
300
mg
Clopidogrel
600
mg
Prasugrel
60
mg
Prasugrel
5
mg
Ticagrelor
90
mg
Ticagrelor
180
mg
42
(16.66)
49
(19.36)
53
(20.94)
2
(0.79)
0
106(41.89)
1
(0.39)
21
(8.50)
55
(22.26)
60
(24.29)
4
(1.62)
2
(0.81)
102
(41.29)
3
(1.21)
0.64
Gp
IIb/IIIa
Inhibitors
–
no.
(%)
None
Abciximab
Tirofiban
Ep+fiba+de
219
(86.56)
10
(3.95)
12
(4.74)
12
(4.74)
214
(86.64)
9
(3.64)
13
(5.26)
11
(4.45)
0.47
Thienopyridines
post-­‐procedure
Clopidogrel
75
mg
Prasugrel
10
mg
Prasugrel
5
mg
Ticagrelor
90
mg
109
(43.08)
2
(0.79)
0
140
(55.33)
105
(42.51)
4
(1.62)
2
(0.81)
136
(55.06)
0.71
An+-­‐aggrega+on
therapy
at
Hospitaliza+on

34. 12
months
Clinical
Events
rino.sardella@uniroma1.it
SMILE
TRIAL
Characteris+cs
SINGLE
Staged
(tot.
=253)
MULTI
Staged
(tot.
=247)
P
value
MACCE
–
no.
(%)
Death
–
no.
(%)
Cardiac
Death
–
no.
(%)
Stroke
–
no.(%)
Myocardial
Infarc+on
Q
–
no.
(%)
non-­‐Q
–
no.
(%)
UA
needing
Hospitaliza+on
TVR
–
no.
(%)
33
(13.04)
14
(5.53)
9
(3.55)
1
(0.39)
7
(2.76)
2
(0.78)
5
(1.98)
11
(4.34)
22
(8.69)
57
(23.07)
28
(11.33%)
13
(5.26%)
0
9
(3.64)
3
(1.21)
6
(2.42)
13
(5.26)
36
(14.57%)
0.0036
0.02
0.38
1
0.61
0.68
0.76
0.67
0.05
Definite
Stent
thrombosis
1
(0.39)
1
(0.40)
1.00
Bleedings
–
no.
(%)
4
(1.56)
12(4.85)
0.03

35. rino.sardella@uniroma1.it
SMILE
TRIAL
Bithérapie
anMagrégante:
quelle
durée
• SECURITY
trial:
6
vs
12
Mo;
TCT
2014
• TLPAS
trial:
prasugrel
12
vs
30
Mo;
AHA
2014
• ITALIC
trial:
6
vs
24
Mo;
AHA
2014
• ISAR
safe
trial:
6
vs
12
Mo;
AHA
2014
• DAPT
trial:
12
vs
30
Mo;
AHA
2014

36. Second
Genera+on
Drug-­‐Elu+ng
Stents
Implanta+on
Followed
by
Six
Versus
Twelve-­‐Month
-­‐
Dual
Antiplatelet
Therapy
-­‐
The
SECURITY
Randomized
Clinical
Trial
Antonio
Colombo
MD
on
behalf
of
the
SECURITY
Inves@gators

37. Baseline
Clinical
Characteris+cs
Characteris+cs
6-­‐Month
DAPT
(N
=
682)
12-­‐Month
DAPT
(N
=
717)
Age
(years),
mean
±
SD
64.9
±
10.2
65.5
±
10.1
Female
sex,
n
(%)
153
(22.4)
166
(23.2)
Diabetes
Mellitus,
n
(%)
206
(30.4%)
223
(31.4%)
Hypertension,
n
(%)
508
(74.5)
510
(71.1)
Dyslipidemia,
n
(%)
446
(65.4)
436
(60.8)
Smoker
Status,
n
(%)
Never
Smoked
274
(40.5)
261
(37)
Previous
Smoker
239
(35.3)
238
(33.7)
Ac+ve
Smoker
139
(20.5)
172
(24.4)
Previous
MI,
n
(%)
NSTEMI
>
48
h
65
(9.5)
71
(9.9)
STEMI
>
48
h
80
(11.7)
73
(10.2)
Previous
PCI,
n
(%)
132
(19.4)
116
(16.2)
Previous
CABG,
n
(%)
38
(5.6)
39
(5.4)
LVEF
(%),
mean
±
SD
56.3
±
8.7
56.6
±
8.2
Clinical
Presenta+on,
n
(%)
Stable
Angina
341
(61.6)
368
(61.6)
Unstable
Angina
213
(38.4)
229
(38.4)
Baseline
Medica+ons
Aspirin,
n
(%)
616
(90.3)
621
(86.6)
Clopidogrel,
n
(%)
301
(44.1)
305
(42.5)
Sta+n,
n
(%)
489
(71.7)
494
(68.9)
Heparin,
n
(%)
377
(55.3)
401
(55.9)

38. Primary
and
Secondary
Composite
Endpoints
P
=
NS
P
=
NS
P
=
NS

39. Stent
Thrombosis
P
=
NS
P
=
NS
P
=
NS
P
=
NS
Definite
/
Probable
Stent
Thrombosis
Possible
Stent
Thrombosis

40. Increased Risk of Ischemic Events Upon Discontinuation Prasugrel After 12 or 30 Months of Therapy
Following Placement of the TAXUS Liberté Paclitaxel- Eluting
Coronary Stent
Kirk
N.
Garram,
Ronald
D.
Jenkins,
Thomas
K.
Pow,
W.
Douglas
Weaver,
Laura
M.
Mauri,
Dean
J.
Kereiakes,
Kenneth
J.
Winters,
Thomas
Christen,
Dominic
J.
Allocco,
and
David
P.
Lee

41. Baseline Characteristics
Characteristic
unless noted)
12-month
Prasugrel + ASA
N=1093 patients
30-month
Prasugrel + ASA
N=1098 patients
Characteristic
(%, unless noted)
12-month
Prasugrel + ASA
N=1093 patients
30-month
Prasugrel + N=1098 patients
74.6 76.3 PCI History 30.9 28.1
years) 59.2 ± 9.5 59.6 ± 9.7 CABG History 12.8 12.0
>75
years
2.7
3.8
Bleeding disorder 0.3 0.5
Weight <60 kg 3.5
3.2
Stable angina 30.6 29.4
Diabetes* 27.3 31.4 Unstable angina 32.6 34.5
Metabolic
Syndrome
12.5
15.7
Silent ischemia 8.0 8.3
Hyperlipidemia* 69.7 68.1 MI 28.2 27.3
Hypertension* 71.0 71.9 NSTEMI 17.9
15.5
History
20.3
20.3
STEMI 9.5
10.7
are % or mean ± SD; *Medically-treated;
MI=myocardial
infarction; PCI=percutaneous coronary intervention; CABG=coronary artery bypass graft

42. At
Risk
Co-Primary Endpoint: MACCE at 540 days
All Death, ARC MI, Stroke
2.4%
0.7%
0
90
180
360
540
630
1093
1089
1055
1030
987
935
1097
1094
1080
1065
1034
991
Time after Randomization (days)
14
12
10
8
6
4
2
0
Cumulative Incidence of
MACCE, % (± 1.5 SE)
9.4%
5.8%
540 Days
P<0.001
630 Days
P<0.001
90 Days
P=0.002
8.8%
3.7%
HR
0.303
[0.137,
0.670]
Cumulative KM Event Rate ± 1.5 SE; log-rank P value; HR=Hazard Ratio [95% confidence interval]
HR 0.407
[0.281, 0.589]
HR 0.591
[0.431, 0.811]
12-mo Prasugrel + ASA
30-mo Prasugrel + ASA

43. Co-Primary Endpoint: Definite or Probable
ARC Stent Thrombosis at 540 days
At
Risk
0
90
180
360
540
630
1093
1087
1065
1042
1011
969
1097
1091
1081
1068
1043
1004
14
12
10
8
6
4
2
0
Cumulative Incidence of
ARC ST, % (± 1.5 SE)
Cumulative KM Event Rate ± 1.5 SE; log-rank P value; HR=Hazard Ratio [95% confidence interval]
2.9%
0.8%
540 Days
P<0.001
630 Days
P<0.001
90 Days
P=0.003
0.8%
0.0%
2.9%
0.2%
Time after Randomization (days)
HR
0.000
[0.000,
NA]
HR 0.063
[0.015, 0.264]
HR 0.252
[0.116, 0.549]
12-mo Prasugrel + ASA
30-mo Prasugrel + ASA

44. Chicago
2014
Is
There
A
LIfe
for
DES
ajer
discon+nua+on
of
Clopidogrel
Six-­‐month
versus
24-­‐month
dual
an+platelet
therapy
ajer
implanta+on
of
drug
elu+ng
stents
in
pa+ents
non-­‐resistant
to
aspirin:
ITALIC,
a
randomized
mul+center
trial
Gilard
M,
Barragan
P,
AL
Noryani
A,
Noor
H
AMajwal
T,
Hovasse
T,
Castellant
P,
Schneeberger
M,
Maillard
L,
Bressoleme
E,
Wojcik
J,
Delarche
N,
Blanchard
D,
Jouve
B,
Ormezzano
O,
Paganelli
F,
Levy
G,
Sainsous
J,
Carrie
D,
Furber
Berlan
J,
Darremont
O,
Le
Breton
H,
Lyuycx-­‐Bore
A,
Gommeaux
A,
Cassat
C,
Kermarrec
A,
Cazaux
P,
Druelles
P,
Dauphin
R,
Armengaud
J,
Dupouy
P,
Champagnac
D,
Ohlmann
P,
Endresen
K,
Ben
Amer
H,
Kiss
R
G,;
Ungi
I,
Boschat
J,
Morice
MC

45. Results
Baseline
Characteris+cs

46. Results
1-­‐year
clinical
outcomes
in
the
inten+on-­‐to-­‐treat
study
popula+on

47. Six versus Twelve Months
of Clopidogrel Therapy
After Drug-Eluting Stenting
– the Randomized, Double-Blind,
Placebo-Controlled ISAR-SAFE Trial
Stefanie Schulz-Schüpke, Julinda Mehilli, Karl-Ludwig Laugwitz, Franz-Josef Neumann, Jurrien M ten
Berg, Tom Adriaenssens, Yaling Han, Barbara von Merzljak, Gert Richardt, Melchior Seyfarth, Klaus
Tiroch, Tanja Morath, Michael Maeng, Bernhard Zrenner, Nonglag Rifatov, Claudius Jacobshagen,
Harald Mudra, Eberhard von Hodenberg, Jochen Wöhrle, Sebastian Kufner, Christian Hengstenberg,
Marcus Fischer, Martin Schmidt, Franz Dotzer, Tareq Ibrahim, Peter Sick, Christoph A Nienaber,
Arnoud W J van 't Hof, Takeshi Kimura, Bernhard Witzenbichler, Stephan Windecker, Heribert
Schunkert, Adnan Kastrati

48. Angiographic and Procedural
Characteristics (1/2)
Six months Clopidogrel
(n=1997)
Twelve months Clopidogrel
(n=2003)
Clinical Presentation, %
- Stable CAD 48.6 47.8
- NSTE-ACS 31.9 32.0
- STEMI 7.9 8.3
- Silent Ischemia 10.9 11.3
- Arrhythmia 0.7 0.6

49. 5
4
3
2
1
0
12 months of clopidogrel
6 months of clopidogrel
0
1
2
3
4
5
6
7
8
9
Months
ater
randomizaMon
Composite
of
death,
MI,
stent
thrombosis,
stroke
or
TIMI
major
bleeding
(%)
Primary Endpoint
1.6%
1.5%
Δ -0.1%, 1-sided 95% CI 0.5%, P Noninferiority <0.001

57. Consistency of Treatment Effect
MACCE (12-30 Months)
Factor N HR and 95% CI Interaction P
< 75 Years N=8929 0.69 (0.57,0.83) 0.22
>= 75 Years N=1032 0.95 (0.59,1.52)
Male N=7435 0.69 (0.56,0.85) 0.46
Female N=2526 0.81 (0.56,1.17)
No diabetes N=6924 0.59 (0.46,0.74) 0.01
Diabetes N=3037 0.95 (0.72,1.25)
No Risk Factors for ST N=5162 0.78 (0.60,1.03) 0.41
Risk Factors for ST N=4799 0.67 (0.53,0.86)
Clopidogrel N=6500 0.80 (0.64,1.01) 0.03
Prasugrel N=3461 0.52 (0.38,0.71)
Placebo better
22
Continued thienopyridine better
0.048
Sirolimus N=1118 0.54 (0.31,0.93)
Zotarolimus N=1264 0.76 (0.44,1.30)
Paclitaxel N=2666 0.52 (0.37,0.71)
Everolimus N=4703 0.89 (0.67,1.18)

59. Oxygen
in
STEMI?
Avoid
trial;
AHA
2015

60. Characteristic
Oxygen
Arm
N=218
No
Oxygen
Arm
N=223
Status
on
arrival
at
the
catheterization
laboratory
Pain
score,
median
(IQR)
2.0
(0.0-­‐4.0)
2.0
(0.5-­‐3.5)
Time
from
Paramedic
on
scene
to
55.0
(46.0,
69.0)
56.5
(48.0,
68.8)
hospital
arrival,
median
(IQR)
Cardiac
arrest,
%
4.6
3.6
Cardiogenic
Shock,
%
5.0
5.4
100%
99%
98%
97%
96%
95%
Arrival
of
paramedics
Arrival
at
hospital
Arrival
at
cath
lab
Oxygen
Arm
No
Oxygen
Arm
2
hours
post
procedure
4
hours
post
procedure
SpO2
in
patients
with
STEMI
P
trend
<0.01
%
of
patients
receiving
oxygen
P
trend
<0.01

61. Primary
Endpoint
Infarct
Size
Area
under
curve
p
=
0.04
Creatine
kinase,
U/L
Oxygen
Arm
N=217
No
Oxygen
Arm
N=222
Ratio
of
means
(Oxygen/No
Oxygen)
P-­‐value
Geometric
Mean
Peak
(95%
CI)
1948
(1721
–
2205)
1543
(1341
–
1776)
1.26
(1.05
–
1.52)
0.01
Median
Peak
(IQR)
2073
(1065,
3753)
1727
(737,
3598)
0.04

62. Clinical
Endpoints
Values
are
%
Oxygen
Arm
N=218
No
Oxygen
Arm
N=223
P-­‐Value
At
Hospital
Discharge
Mortality
1.8
4.5
0.11
Recurrent
myocardial
infarction
5.5
0.9
<0.01
Stroke
1.4
0.4
0.30
Major
bleeding
4.1
2.7
0.41
SigniWicant
arrhythmia
40.4
31.4
0.05
ECG
ST-­‐segment
resolution
>
70%
62.0
69.6
0.10
At
6
months
follow
up
Mortality
3.8
5.9
0.32
Recurrent
myocardial
infarction
7.6
3.6
0.07
Stroke
2.4
1.4
0.43
Repeat
revascularization
11.0
7.2
0.17
MACCE
21.9
15.4
0.08

63. ESC 2014 guidelines on revascularisa6on
PCI in STEMI

64. ESC 2014 guidelines on revascularisa6on
PCI in NST ACS

65. An6thrombo6c therapy in NST ACS
ACC/AHA guidelines 2014

66. ESC
2014
guidelines
on
revascularisaMon
PCI
in
NST
ACS
In
summary,
it
is
recommended
that
DAPT
be
administered
for
at
least
1
month
ater
BMS
implantaMon
in
SCAD,
for
6
months
ater
new-­‐genera+on
DES
implantaMon
in
SCAD,
and
for
up
to
1
year
in
paMents
ater
ACS,
irrespecMve
of
revascularizaMon
strategy

67. 67

68. Aspirine: faut-­‐il meIre les pa6ents sous aspirine avant
chirurgie non cardiaque?
POISE-­‐2 trial ACC 2014, NEJM 2014

69. Type
of
surgery
and
periop
an+coagulant
prophylaxis
Surgery
Aspirin
(N=4998)
Placebo
(N=5012)
Orthopedic
General
Urologic
or
gynecologic
Vascular
Other
38.2
26.8
16.7
6.2
12.1
39.2
26.8
16.8
5.9
11.3
65%
of
paMents
received
prophylacMc
anMcoagulant

70. 1O and 2O outcome results
Outcome
Aspirin
(4998)
Placebo
(5012)
HR
(95%
CI)
P
outcome:
death
or
nonfatal
MI
351
(7.0)
355
(7.1)
0.99
(0.86-­‐1.15)
0.92
outcomes:
death,
MI,
or
stroke
362
(7.2)
370
(7.4)
0.98
(0.85-­‐1.13)
0.80
death,
MI,
revasc,
PE,
DVT
402
(8.0)
407
(8.1)
0.99
(0.86-­‐1.14)
0.90
No
interacMon
with
clonidine
study
drug

71. Safety outcome results
Outcome
Aspirin
(4998)
Placebo
(5012)
HR
(95%
CI)
P
Major
bleed
229
(4.6)
187
(3.7)
1.23
(1.01-­‐1.49)
0.04
Life-­‐threat
bleed
87
(1.7)
73
(1.5)
1.19
(0.88-­‐1.63)
0.26
Stroke
16
(0.3)
19
(0.4)
0.84
(0.43-­‐1.64)
0.62

72. LCZ696, angiotensin receptor neprilysin inhibitor
PARADIGM HF trial, ESC 2014; NEJM 2014
05/12/14
Footer
Text
73

73. LCZ696: Angiotensin Receptor Neprilysin Inhibition
LCZ696
Angiotensin
receptor blocker
Inhibition of
neprilysin

74. PARADIGM-HF: Cardiovascular Death or Heart
Failure Hospitalization (Primary Endpoint)
40
32
24
16
8
0
Enalapril
(n=4212)
0 180 360 540 720 900 1080 1260
Days After Randomization
4187
4212
3922
3883
3663
3579
3018
2922
2257
2123
1544
1488
896
853
249
236
Patients at Risk
LCZ696
Enalapril
1117
Kaplan-Meier Estimate of
Cumulative Rates (%)
914
LCZ696
(n=4187)
HR = 0.80 (0.73-0.87)
P = 0.0000002
Number needed to treat = 21

75. PARADIGM-HF: Cardiovascular Death
Enalapril
(n=4212)
LCZ696
(n=4187)
HR = 0.80 (0.71-0.89)
P = 0.00004
Number need to treat = 32
Kaplan-Meier Estimate of
Cumulative Rates (%)
Days After Randomization
32
24
16
8
4187
4212
4056
4051
3891
3860
3282
3231
2478
2410
1716
1726
1005
994
280
279
Patients at Risk
LCZ696
Enalapril
0 180 360 540 720 900 1080 1260
0
693
558