Antithrombotic therapy in acute coronary syndromes: which agent and when? Giuseppe Biondi Zoccai Divisione di Cardiologia, Università di Torino [email protected]Aggiornamenti in tema di fibrillazione atriale, imaging 3D ed infarto acuto - Torino, 18/10/2008
47
Embed
Antithrombotic therapy in acute coronary syndromes: which agent and when? Giuseppe Biondi Zoccai Divisione di Cardiologia, Università di Torino [email protected].
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
• DIRECT THROMBIN INHIBITORSDIRECT THROMBIN INHIBITORS (eg bivalirudin): as replacement of UFH or LWM for HIT, in NSTEACS patients at high-risk of bleeding but low risk of ischemic events, and in most STEMI
• FONDAPARINUXFONDAPARINUX: 2.5 mg SC daily in patients managed non-urgently or conservatively
• GPIIB/IIIA INHIBITORSGPIIB/IIIA INHIBITORS: in high-risk patients, provisionally in others (abciximab or eptifibatide in the cath lab if angio<2.5 h or provisional use; eptifibatide or tirofiban if angio<48 h)
• LMW HEPARINLMW HEPARIN (eg 10 mg/Kg SC enoxaparin twice daily): if invasive strategy is not applicable or deferred
• UNFRACTIONED HEPARINUNFRACTIONED HEPARIN: 50-100 IU/Kg IV bolus and additional doses aiming for target ACT (250–350 s without GpIIb/IIIa inhibitors, and 200–250 with them) if immediate or early invasive strategy
• PRASUGREL/CANGRELORPRASUGREL/CANGRELOR: not yet CE-marked
G. Biondi Zoccai – Terapia antitrombotica: quale farmaco e quando >>>>>>When and how
Bassand et al, EHJ 2007
Learning goals
• What is the scope of ACS?
• What is the role of antiplatelet agents in ACS?
• What is the role of anticoagulants in ACS?
• When and how should antithrombotic agents be given?
• Does on size fit all?
G. Biondi Zoccai – Terapia antitrombotica: quale farmaco e quando >>>>>>>Sizing
Finding the balance between ischemic and
bleeding risk: an easy case
Finding the balance between ischemic and
bleeding risk: an easy case
Finding the balance between ischemic and
bleeding risk: another easy case
Finding the balance between ischemic and
bleeding risk: another easy case
What about tougher cases?
Predicting ischemic risk
Antman et al, JAMA 2000;284:835-42
TIMI Score
* all-cause mortality, myocardial infarction, and severe recurrent ischemia prompting urgent revascularization
*
VARIABLEMULTI-
VARIABLE PODDS RATIO POINT
Age>65 years <0.001 1.75 1
>2 risk factors for CAD
0.003 1.54 1
Significant CAD <0.001 1.70 1
ST deviation 0.005 1.51 1
Severe angina 0.001 1.53 1
Aspirin in last week
0.006 1.74 1
Raised cardiac markers
<0.001 1.56 1
G. Biondi Zoccai – Terapia antitrombotica: quale farmaco e quando >>>>>>>Sizing
Nikolski et al, EHJ 2007
Predicting bleeding risk
G. Biondi Zoccai – Terapia antitrombotica: quale farmaco e quando >>>>>>>Sizing
A new composite end-point: net adverse clinical events (NACE)
Ndrepepa et al, J Am Coll Cardiol 2008;51:690-7
DEATHDEATH
MIMI
STROKESTROKE
PCI/ CABGPCI/ CABG
MAJOR MAJOR BLEEDINGBLEEDING
ALL CAN ALL CAN IMPACT ON IMPACT ON
PROGNOSIS, PROGNOSIS, SYMPTOMS, SYMPTOMS, AND COSTS!AND COSTS!BUT EACH BUT EACH
MAY IMPACT MAY IMPACT THESE IN THESE IN
DIFFERENT DIFFERENT DIRECTIONSDIRECTIONS
*in several cases, stroke is not included in NACE definition
DEATHDEATH
MIMI
STROKESTROKE
PCI/ CABGPCI/ CABG
MAJOR MAJOR BLEEDINGBLEEDING
ALL CAN ALL CAN IMPACT ON IMPACT ON
PROGNOSIS, PROGNOSIS, SYMPTOMS, SYMPTOMS, AND COSTS!AND COSTS!BUT EACH BUT EACH
MAY IMPACT MAY IMPACT THESE IN THESE IN
DIFFERENT DIFFERENT DIRECTIONSDIRECTIONS
NACE: composite of all cause death, non-fatal myocardial infarction, non-fatal stroke,
PCI/CABG, and non-fatal major bleeding*
A new composite end-point: net adverse clinical events (NACE)
Take home messages
1. A comprehensive appraisal of thrombotic & bleeding risks is needed in patients with ACS
THROMBOSIS
BLEEDING
2. Better yet practical risk-stratification tools for bleeds and
thromboses are warranted
3. Every patient will have an individualized treatment with different agents, timing and dosage of administration, depending