http://www.theheart.org/web_slides/1144191.do
A randomized to prasugrel or clopidogrel study on TRITON-TIMI 38 with patients who have moderate- to high-risk ACS.
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
http://www.theheart.org/web_slides/1144191.do
A randomized to prasugrel or clopidogrel study on TRITON-TIMI 38 with patients who have moderate- to high-risk ACS.
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
Among patients with or at high risk of CVD, use of an FDC strategy for blood pressure, cholesterol, and platelet control vs usual care resulted in significantly improved medication adherence.Polypill therapy significantly improved adherence, SBP and LDL-cholesterol in high risk patients compared with usual care, especially among those who were under-treated at baseline.
What are anti-coagulants?
What are the difference between antiplatelet, anticoagulants and thrombolytics?
Coagulation cascade
Virchows Triad
Classification of anti-coagulants?
Indications of anti-coagulants?
Mechanism and site of action of different anti-coagulants?
Among patients with or at high risk of CVD, use of an FDC strategy for blood pressure, cholesterol, and platelet control vs usual care resulted in significantly improved medication adherence.Polypill therapy significantly improved adherence, SBP and LDL-cholesterol in high risk patients compared with usual care, especially among those who were under-treated at baseline.
What are anti-coagulants?
What are the difference between antiplatelet, anticoagulants and thrombolytics?
Coagulation cascade
Virchows Triad
Classification of anti-coagulants?
Indications of anti-coagulants?
Mechanism and site of action of different anti-coagulants?
Secondary Prevention after ACS: Focused on Anticoagulant TherapyPERKI Pekanbaru
Dr. Nathania Marliani Kristanti, SpJP, FIHA. 3rd Pekanbaru Cardiology Update, August 25th 2013. Pangeran Hotel Pekanbaru. Learn more at PerkiPekanbaru.com
Strategy to Go for Goal in Dyslipidemia with Acute Coronary Syndrome PatientsPERKI Pekanbaru
Dr. A. Fauzi Yahya, SpJP (K), FIHA, FAsCC. 3rd Pekanbaru Cardiology Update, August 24th 2013. Pangeran Hotel Pekanbaru. Learn more at PerkiPekanbaru.com
Dr. Nathania Marliani Kristanti, SpJP, FIHA. 3rd Pekanbaru Cardiology Update, August 24th 2013. Pangeran Hotel Pekanbaru. Learn more at PerkiPekanbaru.com
Diabetes and acute coronary syndrome
Diabetic patients as compared to non diabetics withacute cornary syndrome (ACS) at 2 years showed a
1.8 fold increase in cardiovascular deaths
1.4 fold increase in myocardial infarctions (MI)
www.srisriholistichospitals.com
PLATO (Platelet Inhibition and Patient Outcomes)theheart.org
- Background:
Ticagrelor, a new antiplatet agent and not a thienopyridine, has a unique mechanism of action in that it is reversible
- Population and treatment:
18 624 ACS patient, with or without ST-segment elevation, randomized in a double-blind, double-dummy fashion to ticagrelor (180-mg loading dose, 90 mg twice daily thereafter) or clopidogrel (300- to 600-mg loading dose, 75 mg thereafter) for one year
Patients also received aspirin 75 mg to 100 mg day, unless they could not tolerate the drug
- Primary outcome:
A composite of death from vascular causes, MI, or stroke
See the article at http://www.theheart.org/article/995621.do
Reestenosis, Síndrome coronario agudo. Rol actual de los nuevos antiplaquetarios en el síndrome coronario agudo. Congreso SOLACI Chile 2011.Dr. Ramón Corbalán. Encuentre más presentaciones en la página www.solaci.org/
Antiplatelet therapy there is a gap between guidelines and implementationA.Salam Sharif
platelets play an important role in cardiovascular diseases, the final event leading to ACS is a spontaneous atherosclerotic plaques which initiates a platelet response with platelet adhesion to vascular wall with activation and agregation and finally clot formation with clinical sequences od CV deaths, MI and myocardial ischemia and arrhythmias, so atiplatelet therapy is crucial in treatment of ACS, in the topic I review the traditional agents and new agents , focusing on guidelines and real world of their cinical uses .
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
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Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
4. Atherothrombosis: A Generalized and
Progressive Disease
Unstable angina
MI
Ischemic
stroke/TIA
Critical leg
ischemia
Intermittent
claudication
CV death
ACS
Atherosclerosis
Stable angina/Intermittent claudication
Atherothrombosis
MI = Myocardial infarction
ACS = Acute coronary syndromes
CV = Cardiovascular
Adapted from Libby P. Circulation 2001; 104: 365–372
5. CURRENT OASIS 7: A 2X2 Factorial Randomized Trial of
Optimal Clopidogrel and Aspirin Dosing in Patients with
ACS Undergoing an Early Invasive Strategy with Intent
For PCI
OASIS-7
Shamir R. Mehta on behalf of the CURRENT Investigators
Disclosures: CURRENT OASIS 7 was funded by a grant from sanofi-aventis and Bristol Myers
Squibb. All data were managed independently of the sponsor at the PHRI, McMaster University and
the trial was overseen by an international steering committee of experts.
6. Study Design, Flow and Compliance
25,087 ACS Patients (UA/NSTEMI 70.8%, STEMI 29.2%)
Planned Early (<24 h) Invasive Management with intended PCI
Ischemic ECG ∆ (80.8%) or ↑cardiac biomarker (42%)
25,087 ACS Patients (UA/NSTEMI 70.8%, STEMI 29.2%)
Planned Early (<24 h) Invasive Management with intended PCI
Ischemic ECG ∆ (80.8%) or ↑cardiac biomarker (42%)
PCI 17,232
(70%)
Angio 24,769
(99%)
Angio 24,769
(99%)
No PCI 7,855 (30%)
No Sig. CAD 3,616 CABG 1,809 CAD 2,430
Randomized to receive (2 X 2 factorial):
CLOPIDOGREL: Double-dose (600 mg then150 mg/d x 7d then 75 mg/d) vs Standard dose (300 mg then 75 mg/d)
ASA: High Dose (300-325 mg/d) vs Low dose (75-100 mg/d)
Efficacy Outcomes: CV Death, MI or stroke at day 30
Stent Thrombosis at day 30
Safety Outcomes: Bleeding (CURRENT defined Major/Severe and TIMI Major)
Key Subgroup: PCI v No PCI
Clop in 1st 7d (median) 7d 7 d 2 d 7d
Complete
Followup
99.8%
Compliance:
7. Days
CumulativeHazard
0.00.010.020.030.04
0 3 6 9 12 15 18 21 24 27 30
Clopidogrel: Double vs Standard Dose
Primary Outcome: PCI Patients
Clopidogrel Standard
Clopidogrel Double
HR 0.85
95% CI 0.74-0.99
P=0.036
15% RRR
CV Death, MI or Stroke
8. Days
CumulativeHazard
0.00.0040.0080.012
0 3 6 9 12 15 18 21 24 27 30
Clopidogrel Standard Dose
Clopidogrel Double Dose
42%
RRR
HR 0.58
95% CI 0.42-0.79
P=0.001
Clopidogrel: Double vs Standard Dose
Definite Stent Thrombosis (Angio confirmed)
10. TRITON: Primary Efficacy Results in Entire ACS
Cohort at 15 Months
Wiviott SD, et al. N Engl J Med 2007;357:2001-15
0
5
10
15
0 30 60 90 180 270 360 450
HR 0.81
(0.73-0.90)
P<0.001
Prasugrel
Clopidogrel
HR 0.80
P=0.0003
HR 0.77
P=0.0001
Days
PrimaryEndpoint%(N)
12.1%
(781)
9.9% (643)
NNT= 46
ITT= 13,608 LTFU = 14 (0.1%)
LTFU = Lost to follow-up
ITT = Intention to treat
11. TRITON: Primary Efficacy and Safety Endpoints in
Entire ACS Cohort at 15 Months
Wiviott SD, et al. N Engl J Med 2007;357:2001-15
0
5
10
15
0 30 60 90 180 270 360 450
Prasugrel
Clopidogrel
Days
Endpoint(%)
12.1
9.9
Prasugrel
Clopidogrel
1.8
2.4
CV Death / MI / Stroke
TIMI Major
NonCABG Bleeds
HR 0.81
(0.73-0.90)
P<0.001
138
events
NNT = 46
HR 1.32
(1.03-1.68)
P=0.03
35
events
NNH = 167
12. %Events
TIMI Major
Bleeds
ARR 0.6%
HR 1.32
P=0.03
Clopidogrel
Prasugrel
Life
Threatening
ARR 0.5%
HR 1.52
P=0.01
Nonfatal
ARR 0.2%
P=0.23
ICH
ARR 0%
P=0.74
Fatal
ARR 0.3%
P=0.002
ICH in Pts w
Prior Stroke/TIA
(N=518)
Clop 0 (0) %
Pras 6 (2.3)%
(P=0.02)
1.8
0.9 0.9
0.1
0.3
2.4
1.4
1.1
0.4 0.3
0
2
4
TRITON: Prasugrel increase Significant Major & Life
Threatening Bleeding Results in Entire ACS Cohort at
15 Months
Adapted Wiviott SD, et al. N Engl J Med 2007;357:2001-15
NNH=167
NNH = Number needed to harm
ARR = Absolute risk reduction
HR = hazard ratio
ICH = intracranial hemorrhage
13. CURRENT PCI
N=17,232
TRITON
N=13,608
CV Death, MI or Stroke ↓ 15%
↓ 21% (w high dose ASA)
↓ 19%
Definite Stent Thrombosis ↓ 42%
↓ 51% (w high dose ASA)
↓ 58%
TIMI Major Bleed No increase ↑ 32%
CABG-related Bleeding No increase ↑ 4-fold
Fatal bleeding No increase ↑ 4-fold
Comparison of CURRENT and TRITON
15. Primary efficacy endpoint: Death from vascular causes/MI/stroke
Secondary efficacy endpoints: Primary endpoint in patients undergoing PCI; all cause
mortality/MI/stroke,vascular death/MI/stroke/severe recurrent ischemia/TIA/arterial thrombotic event;
stent thrombosis; all-cause mortality
Primary safety endpoint: PLATO-defined major bleeding
12-month maximum exposure
(Min = 6 mo, Max = 12 mo, Mean = 11 mo)
(N>18,000)
ASA* + Clopidogrel
300-mg LD/75 mg qd†
Additional 300-mg LD allowed in PCI
ASA* + AZD6140
180-mg LD/90 mg bid†
Additional 90 mg LD allowed in PCI >24 h
after randomization
ACS patients
(UA/NSTEMI/STEMI, PCI,
medically managed, or CABG)
*All patients received ASA 75-100 mg qd unless intolerant.
ASA = acetylsalicylic acid; LD = loading dose; PLATO = PLATelet inhibition and patient Outcomes trial.
James S et al. Am Heart J. 2009;157:599-605.
PLATO Study Design
Dose of study drug assigned as soon as possible (≤ 24 h) after index event
16. 4
8
2
6
Primary efficacy endpoint over time
(composite of CV death, MI or stroke)
*Excludes patients with any primary event during the first 30 days
0
Clopidogrel
Cumulativeincidence(%)
Ticagrelor
HR 0.88 (95% CI 0.77–1.00), p=0.045
0 10 20 30
Days after randomisation
5,43
4.77
No. at risk
Ticagrelor 9,333 8,942 8,827 8,763
Clopidogrel 9,291 8,875 8,763 8,688
8
0
Clopidogrel
2
4
6
Cumulativeincidence(%)
Ticagrelor
0 90 150 330
Days after randomisation
8,673 8,543 8,397 7,028 6,480 4,822
8,688 8,437 8,286 6,945 6,379 4,751
210 270
6.60
5.28
HR 0.80 (95% CI 0.70–0.91), p<0.001
Wallentin L et al. New Engl J Med.2009;361:DOI:10.1056/NEJMoa0904327. http://www.clinicaltrialresults.org/
17. PLATO : No Significant different in Sub Analysis for UA
21. PLATO : Ticaglerol Increase Intracranial
bleeding & Fatal ICH
P=0.06 HR
1.87
P=0.02
HR=5.47
K-Mestimatedrate(%peryear)
ICH
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
Fatal ICH
0.28
0.15
0.12
0.01
Ticagrelor
Clopidogrel
Ticagrelor (N=9235) 26 11
Clopidogrel (N=9186) 14 1
Wallentin L et al. N Engl J Med. 2009 Sep 10;361(11):1045-57.
FDA website CardiovascularandRenalDrugsAdvisoryCommittee/ucm192863.htm. Accessed on August 23rd, 2010.
22. Bleeding is a serious event
Moscucci et al, Eur Heart J 2003
*
* p<0.01
Bleeding associated with higher mortality after ACS
23. Ndrepepa et al, J Am Coll Cardiol 2008
5384 patients from 4 RCT’s, PCI studies, Stable CAD and ACS
Bleeding is a serious event
Same impact on long term mortality than new MI
24. Verheugt et al, JACC Cardiovasc Interv 2011
Recurrent events and Mortality
17393 PCI patients from 3 RCT’s (REPLACE 2, ACUITY and
HORIZON)
Bleeding is a serious event
Greater impact on prognosis of non access site
bleedings
25. All Access-site bleeding impact mortality ?
Access-site bleeding impact mortality only if associated with Ht decrease
Romaguera et al, Am J Cardiol 2012
7718 PCI patients, single center registry, femoral access
26. Two Types of Bleedings
In Hospital Bleedings (Procedure/Antithrombotic therapy)
Post Discharge Bleedings (Oral Antiplatelet Therapy)
27. After Discharge
Low dose aspirin
Individualized P2Y12 inhibitors
Use of PPI
Monitoring ?
In Hospital
- Radial Access +++
- Careful use of anticoagulant
- Shorten Duration of Therapy
- Selective use of GPIIbIIIa
How to prevent bleedings in ACS/PCI patients ?
28. 0
108
Placebo APTC CURE
Antiplatelet Therapy in ACS
Single
Antiplatelet Rx
Dual
Antiplatelet Rx
Higher IPA
ASA
ASA + Clopidogrel ASA +
New P2Y12 blockers
- 22%
- 20%
- 19%
+ 60% + 38%
+ 32%
Reduction in
Ischemic Events
Increase in
Major Bleeds
Placebo
29. 0 30 60 90 180 270 360 450 days
5
10
Endpoint(%)
0
9.8
11.7
Ticagrelor 90mg x2
HR 0.84 (0.77–0.92) p=0.0003*
12.1
9.9
Prasugrel 10mg
Clopidogrel 75mg
HR 0.81 (0.73-0.90) p=0.0004*
TRITON and PLATO
Primary endpoint = CV Death / MI / Stroke 12-15 months
Wiviott et al, NEJM 2007, Wallentin et al, NEJM 2010
30. p=0.03* p=0.025*
7
6
5
4
3
2
1
0
2.8
2.2
Safety = Non-CABG related TIMI major bleedings
1.8
2.4
p=0.001*
2.7
3.7
450 days
ASAonly
360 days360 days
+38% +32% +27%
Ticagrelor
Clopidogrel 75
Prasugrel
TRITON PLATOCURE
Same Platelet InhibiƟon → Same Bleeding Risk
NNH=167 NNH=167
Wiviott et al, NEJM 2007, Wallentin et al, NEJM 2010
31. High risk
STEMI
Diabetes mellitus, CKD
High-risk NSTE ACS
(Tn + and/or ST changes)
Recurrent event on clopidogrel
Stent Thrombosis
Low risk
No ST changes
No Troponin elevation
(Patients not in Triton / Plato)
High risk:
Prior stroke/TIA*
Age > 75 y.o
Weight < 60 kg
Chronic OAC, Prior Bleeding
Low risk
No prior stroke/TIA/Bleeding
Age < 75 y.o
Weight > 60 kg
No Chronic OAC
Ischemic Risk
Bleeding Risk
P2Y12 Blockers
Individual Decision Clopidogrel
Clopidogrel
ACS patients
* CI Prasugrel
Prevention of Post discharge Bleedings
32. STEMI: Oral antiplatelets
What, when and how?
WHAT?
WHEN?
HOW?
Aspirin
Clopidogrel / Prasugrel* / Ticagrelor*
Aspirin
Clopidogrel
ASAP
Aspirin: started at a dose of 150–300mg per os or 250–
500mg bolus iv followed by 75-100mg daily
Prasugrel: 60mg LD followed by 10mg daily, or
Ticagrelor: 180mg LD followed by 90mg twice daily, or
Clopidogrel: 600mg LD followed by 75mg daily
Aspirin: oral dose of 150-325mg or i.v. dose of 250mg
if oral ingestion is not possible.
Clopidogrel: loading dose of 300mg if age ≤75 years;
75mg if age >75 years
1. Wijns W et al Eur Heart J 2010;31:2501-55
2. Van de Werf F et al Eur Heart J 2008;29:2909-45
Primary PCI1 Thrombolysis2
33. Invasive 1,2 Conservative 2
WHAT?
WHEN?
HOW?
Aspirin
Ticagrelor* / Clopidogrel‡
Aspirin
Ticagrelor* / Clopidogrel‡
Loading dose ASAP
Aspirin: started at a dose of 150–300 mg and at a
maintenance dose of 75–100 mg, plus
Ticagrelor: 180 mg LD, 90 mg twice daily, or
Clopidogrel: 300 or 600 mg LD, 75 mg daily
Upstream GPIIbIIIa are not recommended in
patients with high ischaemic risk
Aspirin: started at 150–300 mg and at a
maintenance dose of 75–100 mg, plus
Ticagrelor 180 mg LD, 90 mg twice daily, or
Clopidogrel: an immediate 300 mg LD, 75 mg
daily dose
1. Wijns W et al Eur Heart J 2010;31:2501-55
2. Hamm CW et al ESC NSTE-ACS Guidelines EHJ 2011; doi:10.1093/eurheartj/ehr236
3. Anderson JL et al Circulation 2007;116:148-304
‡All patient received clopidogrel LD before PCI in CURRENT
* Ticagrelor has limited experience for prePCI loading
Patients with low-likelihood of ACS, and lowest-risk ACS were excluded from clinical trials
=> Recommendations apply to NSTEMI for which the diagnosis is likely or definite 3 and should be adapted
to patient risk level for thrombosis and bleeding 2,3
NSTE-ACS : Antiplatelets
What, when and how?
36. ACC AHA - PCI
- Loading dose for all P2Y12 inhibitors is recommended (Class I-A)
- 600 mg loading recommended for clopidogrel
- Limitations imposed on prasugrel
- Issue of compliance posed against ticagrelor
39. Summary
Clopidogrel Prasugrel Ticagrelor
Major study CURE TRITON-TIMI 38 PLATO
Population NSTEACS ACS - PCI ACS
Loading dose 300 mg 60 mg 180 mg
Maintenance dose 75 mg 10 mg 90 mg
Maintenance schedule Daily Daily Twice daily
Treatment arms Clopidogrel vs placebo
Prasugrel vs
clopidogrel
Ticagrelor vs
clopidogrel
Duration of follow-up 9 months 14.5 months 9 months
CV death, MI, stroke
9.3 vs 11.4%
RR 0.80, p < 0.001
9.9 vs 12.1%
HR 0.81, p < 0.001
9.8 vs 11.7%
HR 0.84, p < 0.001
TIMI non-CABG major bleeding
1.1 vs 1.2%*
RR 0.94, p = 0.7
2.4 vs 1.8%
HR 1.32, p = 0.03
2.8 vs 2.2%
HR 1.25, p = 0.03
Major bleeding per study definition
3.7 vs 2.7%
RR 1.38, p = 0.001
2.4 vs 1.8%
HR 1.32, p = 0.03
11.6 vs 11.2%
HR 1.04, p = 0.43
Yusuf S et al. N Engl J Med. 2001;345:494-502.
Wiviott SD et al. N Engl J Med 2007;357:2001-15
Wallentin L et al. N Engl J Med. 2009;361(11):1045-57.
*TIMI major bleeding