Spandana collection

1. Rosutor
Gold Cardio Connect E CME
“Adding more years to life in ACS patients”

2. 2
Case Scenario:
59-yr-old man
Medical history : Coronary artery disease,
hypertension, and hyperlipidemia
Symptoms : sudden onset headache, mild
dysmetria, and severe nausea
Findings
On admission to the intensive care unit
(CT) scan demonstrated a left paramedian
cerebellar hemorrhage measuring 29 × 18
mm with partial effacement of the fourth
ventricle
Anesthesiology. 2014;121(3):644-653. doi:10.1097/ALN.0000000000000350

3. Why we are using DAPT post ACS

4. Is it prevent only stent Thrombosis ?
Stent thrombosis is prevented by combined thienopyridine and
aspirin but not by aspirin and or warfarin

5. “Nowitisaboutpatientsnotstents”

7. DAPT Regime

8. Guideline recommendation on
antithrombotic drugs in STEMI and NSTEMI

9. • Use of antithrombotic drugs in patients undergoing PCI

10. • Antithrombotic therapy in non-ST-segment elevation ACS patients

11. Recommendations for duration of DAPT in
patients who undergo elective PCI

12. Recommendations for duration of DAPT in patients who
undergo elective PCI
Mehta SR, et al. Can J Cardiol. 2018 Mar;34(3):214-233.

13. Recommendations for duration of DAPT
in patients with ACS who undergo PCI

14. Recommendations for duration of DAPT in patients
with ACS who undergo PCI
PCI for STEMI or NSTEACS
DAPT for 1 year ASA 81 mg once daily + Ticaglor 90 mg BID or prasugrel 10
mg once daily preferred over clopidogrel 75 mg once daily
At 1 year, determine bleeding risk
Not at high risk of bleeding High risk of bleeding
Continue DAPT for up to 3 years
ASA 81 mg once daily + Ticaglor
60 mg BID or Clopidogrel 75
ASA 81 mg once daily or
Clopidogrel 75 mg once daily or
Clopidogrel 75 mg once daily
Mehta SR, et al. Can J Cardiol. 2018 Mar;34(3):214-233.

16. Benefit of DAPT score to assess the risk and
duration of DAPT therapy

17. DAPT Duration
Standard DAPT: 12 months
Shorter DAPT: 1, 3 or 6 months
Prolonged DAPT: 24 or 36
months
" EuroIntervention 13.6 (2017): 717-733.

18. Patient profiles for the extended DAPT therapy

19. Clinical characteristics that may benefit from
extended duration of DAPT
Howard CE, et al. J Am Heart Assoc. 2019;8(20):e012639.

20. Patient profiles for the statin therapy

21. ESC 2019 Treatment goals for (LDL-C) across
categories of total CV disease risk

22. New LDL-C and non-HDL-C treatment goals & Risk
Category – LAI 2022

23. •Non-adherence to DAPT + Statin and increase CV
mortality
•Benefit of fixed dose combination therapy in ACS

24. Withdrawers displayed a higher rates of death/myocardial
infarction/stroke (13.5% versus 5.6 %)
Data from the
PURE study
Current Cardiology Reports 17(12):121 October 2015, European Heart Journal (2014) 35, 3267–3276

25. Clinical benefit of DAPT + Statin combination in long
term survival benefit

26. ASPIRIN, CLOPIDOGREL, AND STATIN
COMBINATIONS
PROVIDES LONG TERM SURVIVAL BENEFIT
DAPT plus statin therapy had improved survival 79%
compared with those receiving noncombination or no
therapy
J Vasc Surg 2018;67:279-86

27. Indian data on patient profile, preference
of fixed dose combination DAPT plus Statin
and duration in ACS

28. The Majority of the ACS patient were in the age group of 40-
60 years
Heart India 2021;9:161-8.

29. The Majority of the ACS patient were on Triple Drug
Therapy of Rosuvastatin ,Clopidogrel, Aspirin for 6-
12 Months and >12 month
78.8% and 78.1% of patients were receiving triple
FDC
of rosuvastatin, clopidogrel, and aspirin
Heart India / Volume 9 / Issue 3 / September-December 2021

30. Barriers for optimal management of
dyslipidaemia post ACS

31. • 70% of non-reperfused STEMI patients received all four medications
(DAPT [aspirin and clopidogrel], anticoagulants, and statins) as
recommended by guidelines.
• Level of adherence was significantly associated with a 54% reduction
in the odds of in-hospital mortality after adjusting for potential
confounders
Global Heart. 2020; 15(1): 8. DOI: https://doi.org/10.5334/gh.394

32. n engl j med 371;23 nejm.org december 4, 2014
Dual antiplatelet therapy
beyond 1 year after placement
of a drug-eluting stent
significantly reduced the risks
of stent thrombosis and major
adverse cardiovascular and
cerebrovascular events

33. OPTIMIZE STUDY
3,120 minimally selected* patients undergoing PCI
with E-ZES in 33 sites in Brazil
Randomization ** (1:1)
Primary endpoint: Net Clinical Benefit † at 12-month FU
* Exclude ACS with + biomarker; prior DES Rx;SVG target
** Stratified by DM and Institution; not blinded
† composite endpoint of all-cause death, MI, CVA and major bleeding
DAPT for 3 months DAPT for 12 months
N = 1,560 N= 1,560
Feres et al. AHJ 2012:164:810 e3
Feres et al. TCT 2013 LBCT
Clinical FU at 1, 3, 6, 12 and 18 months and yearly up to 3 yrs

34. OPTIMIZE : NACCE at 1 Year
(All-Cause Death, MI, Stroke, Major Bleeding)
No. at risk
3M DAPT 1563 1520 1504 1468 1384
12M DAPT 1556 1514 1497 1466 1381
Log-Rank P = 0.838
Cumulative
Incidence
of
NACCE
(%)
Time After Initial Procedure (Months)
0 12
0
10
15
5
3 6 9
6.0
5.8
12M DAPT
3M DAPT
Feres et al. TCT 2013 LBCT

35. OPTIMIZE: Stent Thrombosis* vs. Major Bleeding
ARC Def./Prob. Stent Thrombosis
3M DAPT
12M DAPT
Time After Initial Procedure (months)
0.26
0.07
P = 0.18
HR 3.97
(0.44-35.49)
0 12
0
10
5
3 6 9
P = 0.64
HR 0.81
(0.34-1.96)
Cumulative
Incidence
(%)
0.4
0.2
Cumulative
Incidence
(%)
P = 0.31
HR 0.50
(0.12-1.99)
Time After Initial Procedure (months)
0 12
0
10
5
3 6 9
P = 0.79
HR 0.87
(0.32-2.40)
12M DAPT
3M DAPT
Major Bleeding
*0.2% absolute difference
~4x 2x
Feres et al. TCT 2013 LBCT
0.6
0.7

36. CHARISMA:
Dual Therapy Vs. ASA Monotherapy
In Symptomatic* Patients
Bhatt et al. JACC 2007;49:1982-1988
*Prior MI, CVA or symptomatic PAD
CD / MI / Stroke

37. Barriers to optimal dyslipidaemia management post ACS
Dyslipidemia control post ACS is suboptimal.
High prevalence of CVD risk factors confers a higher risk of CVD
ACS onset is often earlier in these patients, and they may be more
challenging to treat
Low awareness of the value of intensive lipid lowering
Patients non-adherence to given medication
Fear of side effect
Lack of follow-up of patients with ACS
Poor access to intensive medications
Economical factors
Reda A, et al. Adv Ther. 2020;37(5):1754-1777.

38. Time course of benefit and risk of antiplatelet therapy
after PCI

39. Choosing who should be considered for prolonged (or
Shorter) duration DAPT
• Factors associated with increased ischemic and bleeding risk
• Risk score calculators

40. Clinical and procedural factors associated with increased
ischemic risk or increased bleeding risk

41. Dual antiplatelet therapy study
“DAPT Score”

42. Incidence of Atrial Fibrillation in ACS patients

43. Myocardial infarction occurred more
frequently in the 6-month DAPT group
than in the 12-month or longer DAPT
group
43

44. Reduced ratesofstentthrombosisandMIafter1yearDAPT
44
n engl j med 371;23 nejm.org december 4, 2014

45. Cardiovascular Drugs & Therapy 17, 467-477; 2003
Clopidogrel is a relatively
new antiplatelet agent & is
currently the most widely
prescribed drugs for the
treatment of symptomatic
coronary artery disease
Clopidogrel

46. Time Distribution of the Switches to Clopidogrel
After the Index Event
Acta Cardiol Sin 2020; 36: 8-15

47. Primary Outcome (Composite: bleeding + MACCE)
• Compared to the ticagrelor only group, the switched group
was not significantly associated with MACCE or CSB events (p
= 0.114)
Acta Cardiol Sin 2020; 36: 8-15

48. Secondary Outcome (MACCEs only)
• There was also no significant difference when MACCEs
were analyzed alone (p = 0.332)
Acta Cardiol Sin 2020; 36: 8-15

49. Secondary Outcome (CSB only)
•For CSB, the switched group 70% less likely to have a CSB event
(p = 0.047)
Acta Cardiol Sin 2020; 36: 8-15

50. CSB Outcomes in 4-weekly Blocks
Acta Cardiol Sin 2020; 36: 8-15

51. MACCE Outcome in 4-weekly Blocks
Acta Cardiol Sin 2020; 36: 8-15

52. Algorithm : Switching between oral P2Y12
Inhibitors in Acute Setting

53. Algorithm : Switching between oral
P2Y12 Inhibitors in Chronic Setting

54. THANKYOU