Top Banner
Luis F. Tami, MD, FACC, FSCAI Interventional Cardiology and Vascular Medicine Director Cardiac Catheterization Laboratory, Memorial Regional Hospital CVI SYMPOSIUM 2012
69

Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

May 26, 2018

Download

Documents

vanphuc
Welcome message from author
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.
Transcript
Page 1: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Luis F. Tami, MD, FACC, FSCAI

Interventional Cardiology and

Vascular Medicine

Director Cardiac Catheterization Laboratory, Memorial Regional Hospital

CVI SYMPOSIUM 2012

Page 2: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

DISCLAIMER

ACS as seen by an Interventional

Cardiologist

Page 3: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

CAD

Basic concepts

Clinical Presentation / case examples

Anatomic and physiological difference between stable and unstable syndromes

Management

Antiplatelet Therapy: Newly approved Prasugrel (Effient) and Ticagrelor (Brilinta)

Page 4: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

46 yr old woman 1 ppd smoker with untreated dyslipidemia and

FHx of CAD comes in at 7 PM with 2 hours of CP.

Page 5: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

LAD and LCx without

significant obst. disease

LCx

LCx

LAD LAD

Page 6: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

ASA/Plavix and

heparin in ER

Reopro in CCL

Additional heparin

Aspiration Catheter

RCA

Page 7: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

PRONTO ASPIRATION CATHETER

Page 8: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Pronto Aspiration Catheters

V3, V4, LP, 035” catheters

Page 9: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Aspiration Thrombectomy Export AP ® Aspiration Catheter

Min 6 F Guide

0.070” Lumen

.014” wire

140 cm long

EXPORT AP*

Page 10: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

ASPIRATE

-Thrombus,

white and red

-Atherosclerotic

plaque

Page 11: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Coronary

SPASM

Page 12: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

IC NTG

Page 13: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 14: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

IntraVascular UltraSound (IVUS)

transducer

1 cm markers

Page 15: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 16: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

ULCERATION

Ruptured Plaque

Page 17: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Xience DES 3.5x 23 mm

Page 18: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 19: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 20: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 21: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

EKG at 10 PM on arrival to ICU. Pain free.

Page 22: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Completely different situation

from stable, chronic CAD

Page 23: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Adaptive

Intimal

Thickening

Intimal

Xanthoma

Pathologic

Intimal

Thickening

LP NC

Fibrous

Cap Atheroma

Thin-Cap

Fibroatheroma

NC

FC

FC = Fibrous cap

LP = Lipid pool

NC = Necrotic core

Extracellular lipid

Necrotic core

Cholesterol clefts

Calcified plaque

Healed thrombus

Macrophage foam cells Hemorrhage

Thrombus

Smooth muscle cells

Collagen

Human Coronary Atherosclerosis Development

Page 24: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Stable Coronary Artery Disease

Pathologic intimal thickening

WHY?

PCI in stable CAD decreases the frequency of angina and

improves exercise performance, without reducing death or MI

STENT ONLY

IF…

-CLASS III

SYMPTOMS

-ISCHEMIA BY

STRESS TEST

FFR: Pressure

gradient

Page 25: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Can you judge “unnecessary stenting”?

Page 26: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 27: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 28: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Number at Risk

OMT 1138 1017 959 834 638 408 192 30

PCI 1149 1013 952 833 637 417 200 35

Years 0 1 2 3 4 5 6

0.0

0.5

0.6

0.7

0.8

0.9

1.0

PCI + OMT

Optimal Medical Therapy (OMT)

Hazard ratio: 1.05

95% CI (0.87-1.27)

P = 0.62

7

PCI in Stable CAD: COURAGE

Median FU 4.6 years

Boden WE et al. NEJM 2007;356:1503-16

Fre

ed

om

fro

m

Dea

th o

r M

I (%

) Death/MI

at 4.6 yrs

19.0%

18.5%

2,287 SIHD STABLE patients randomized to PCI+OMT vs. OMT

Page 29: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

*13 RCTs in 7,605 patients

TAKE HOME MESSAGE #1:

Page 30: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

FAME: Primary Endpoint

Tonino PAL et al. NEJM 2009;360:213–24

FFR-guided

(n=509)

30 days

2.9% 90 days

3.8%

180 days

4.9%

360 days

5.1%

Angio-guided (n=496)

FFR assessment → PCI deferred in 37.0% of lesions

Days

Fre

edo

m f

rom

dea

th,

MI,

rev

asc

0 60 120 180 240 300 360

0.70

0.75

0.80

0.85

0.90

0.95

1.00

MACE 13.2% vs. 18.3%

P=0.02

1005 pts with MVD undergoing PCI with DES were randomized to FFR-

guided vs. angio-guided intervention

Page 31: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

*13 RCTs in 7,605 patients

TAKE HOME MESSAGE #2 :

Page 32: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 33: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Th

Plaque Rupture

nc

Ruptured

cap

th

*

• Lipid rich necrotic core

• Thin fibrous cap (<65 um)

• Cap = type 1 collagen with few SMC

and infiltrated by M and Lymph TCFA =

TCFA

Thin Cap Fibroatheroma (TCFA) is the Precursor Lesion of Plaque Rupture

Thin fibrous

cap

Page 34: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 35: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 36: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 37: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Acute Coronary Syndromes (ACS)

Acute Coronary Syndromes

UA/NSTEMI STEMI

1.42 million

admissions per year

0.41 million

admissions per year National Hospital Discharge Survey 1998. National Center for Health Statistics/Centers for Disease Control and

Prevention. Series 13, No.14. September 2000.

Page 38: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Clinical Manifestations of Arterial Thrombosis

UA/NSTEMI Partially-occlusive thrombus

(primarily platelets)

Intra-plaque

thrombus (platelet dominated) Plaque core

STEMI occlusive thrombus (platelets,

red blood cells, and fibrin)

Intra-plaque

thrombus (platelet dominated) Plaque core

SUDDEN DEATH Adapted from Davies MJ. Circulation.

1990; 82 (supl II): 30-46.

Vulnerable Plaque

Page 39: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Non-Q-wave MI1 Angiography 48/350 (14%)

Acute MI2 Angiography 100/253 (39%)

Unstable angina3 Angiography 128/228 (56%)

ACS4 IVUS 19/24 (79%)

Post-MI5 Angioscopy 20/20 (100%)

Study Diagnostic technique

Patients with multiple plaques (%)

Prevalence of Multiple Coronary Plaques in

Patients With Acute Coronary Syndrome

1. Kerensky R. JACC. 2002;39:9:1456-1462. 4. Rioufol G. Circulation. 2002;106:804-808.

2. Goldstein AR. et al. N Engl J Med. 2000; 343:915-922. 5. Asakura M. JACC. 2001;37:5:1284-1288.

3. Zairis M. Atherosclerosis. 2002;164:355-359.

Page 40: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

PLATELET

HEMOSTATIC CELL

INFLAMMATORY

PATHOGENIC ROLE IN

ATHEROSCLEROSIS:

THROMBOSIS

Page 41: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

PLATELET MEDIATED THROMBOSIS

ADHESION ACTIVATION AGGREGATION

Page 42: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

12 years

Page 43: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Antiplatelet Trialists’ Collaboration

Meta-analysis of Antiplatelet Agents

*Events = MI, stroke, or vascular death

Antiplatelet Trialists’ Collaboration. BMJ. 1994;308:81–106.

Reduction of CV Events*

Aspirin vs Placebo 25%

Dipyridamole vs Placebo 16%

Ticlopidine vs Placebo 33%

Ticlopidine vs Aspirin 10%

DP + Aspirin vs Aspirin - 1%

Overview of 174 randomized trials

in 100,000 individuals

Page 44: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Efficacy of Aspirin Doses on Vascular Events in

High Risk Patients

Adapted with permission from the BMJ Publishing Group. Antithrombotic Trialists’ Collaboration. BMJ. 2002;324:71-86.

0 0.5 1.0 1.5 2.0

500–1500 mg 34 19

160–325 mg 19 26

75–150 mg 12 32

<75 mg 3 13

Any aspirin 65 23

Antiplatelet Better Antiplatelet Worse

Aspirin Dose # Trials OR* (%)

*Odds reduction.

Treatment effect P < 0.0001.

Odds Ratio

Page 45: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

0

2

4

6

ASA only ASA+Warfarin ASA+ Ticlid

3.6%

2.7%

Leon M et al. N Engl J Med. 1998.

0.5%

Antiplatelet Therapy in Reducing Ischemic

Events after Coronary Stenting : STARS

N = 1653

Event rate: Death, MI, CABG or

Reintervention (%)

Page 46: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

P2Y12 Reactivity on Clopidogrel:

PRU (n=94)

0

2

4

6

8

10

12

14

16

18

20

<100 100-149 150-199 200-249 250-299 300-349 350-399 >400

PRU using VerifyNow

Page 47: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

-20.0

0.0

20.0

40.0

60.0

80.0

100.0

Inh

ibit

ion

of

Pla

tele

t A

gg

reg

ati

on

(%

)

Response to Prasugrel Response to Clopidogrel

Clopidogrel Responder

Clopidogrel Non-responder

*Responder = 25% IPA at 4 and 24 h

Inte

rpati

en

t V

ari

ab

ilit

y

Inte

rpati

en

t

Vari

ab

ilit

y

Brandt JT et al., Am Heart J 2007;153:e9-e16.

Inhibition of Platelet Aggregation: Clopidogrel(PLAVIX) Vs. Prasugrel (EFFIENT)

Healthy Volunteers at 24 Hours, N=68

Page 48: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

N

S

O

Cl

O CH3 C

Clopidogrel

Pro-drugs

3

N

S

O

C H

C O

F O

Thienopyridines: Equipotent Active Metabolite

Prasugrel

Gut

Mega JL, NEJM 2008 and Mega JL Circ 2009

Page 49: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

PLATELET INHIBITION

30 min

MORE RAPID

MORE

POWERFUL

MORE

PREDICTABLE

Page 50: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

TIMI-38 Study Design

Double-blind

ACS (STEMI or UA/NSTEMI) & Planned PCI

ASA

PRASUGREL

60 mg LD/ 10 mg MD

CLOPIDOGREL

300 mg LD/ 75 mg MD

CV death, MI, Stroke

Stent Thrombosis

Safety endpoints: TIMI major bleeds, Life-threatening bleeds

Median duration of therapy - 12 months

N= 13,600

Page 51: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Please see Important Safety Information, including Boxed Warning, and Full Prescribing Information provided.

Page 52: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Stent Thrombosis Rates at End of Study

Page 53: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Diabetic Subgroup

0

2

4

6

8

10

12

14

16

18

0 30 60 90 180 270 360 450

HR 0.70

P<0.001

Days

En

dp

oin

t (%

)

CV Death / MI / Stroke

TIMI Major

NonCABG Bleeds

N=3146

17.0

12.2

Prasugrel

Clopidogrel

Prasugrel

Clopidogrel 2.6

2.5

Page 54: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Please see Important Safety Information, including Boxed Warning, and Full Prescribing Information provided.

Page 55: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Stent Thrombosis Rates at End of Study

Page 56: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

Diabetic Subgroup

0

2

4

6

8

10

12

14

16

18

0 30 60 90 180 270 360 450

HR 0.70

P<0.001

Days

En

dp

oin

t (%

)

CV Death / MI / Stroke

TIMI Major

NonCABG Bleeds

N=3146

17.0

12.2

Prasugrel

Clopidogrel

Prasugrel

Clopidogrel 2.6

2.5

Page 57: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

TIMI Major Non-CABG Bleeds

Subgroups

% E

ve

nts

Clopidogrel

Prasugrel

P=0.24

P=0.06

P=0.09

P=0.11

P=0.06

P=0.08

N=1785

(13%)

N=11,672

(87%)

N=664

(5%)

N=12,672

(95%)

N=509

(4%)

N=12,948

(96%)

Age Weight CVA/TIA

History

Contraindicated Give 5 mg/d Caution

Page 58: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 59: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

HOW ABOUT BRILINTA

(TICAGRELOR) ?

Page 60: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

30 min

MORE RAPID

MORE

POWERFUL

MORE

PREDICTABLE

REVERSIBLE

Page 61: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 62: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

PLATO STUDY DESIGN

Primary endpoint: CV death + MI + Stroke

Primary safety endpint: Total major bleeding

6–12-months FU

Clopidogrel

If pre-treated, no additional loading dose;

if naive, standard 300 mg loading dose,

then 75 mg qd maintenance;

(additional 300 mg allowed pre PCI)

Ticagrelor

180 mg loading dose, then

90 mg bid maintenance;

(additional 90 mg pre-PCI)

NSTE-USA (moderate-to-high risk) STEMI (if primary PCI)

Clopidogrel-treated or -naive;

(N=18,624)

Patients could be included whether the intend was to manage patient invasively or medically

Page 63: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 64: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 65: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 66: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 67: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 68: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core
Page 69: Luis F. Tami, MD, FACC, FSCAI - cvisymposium.comcvisymposium.com/sitebuildercontent/sitebuilderfiles/acs2012.pdfLuis F. Tami, MD, FACC, FSCAI ... LP = Lipid pool NC = Necrotic core

TAKE HOME MESSAGES

Both Brilinta and Effient are more effective than Plavix in ACS patients in terms of

reduction in MI, stent thrombosis, especially in diabetics (Effient) . Brilinta reduced

CV mortality in a more wide spectrum patient population

Both are fast, more powerful and consistent than plavix. Whereas Effient is a cath

lab drug, Brilinta is also indicated in post CABG or medically treated patients

Brilinta is reversible inhibitor and has not been compared head to head with Effient.

Effient is contraindicated in patients with TIA and stroke

Brilinta should be used with 81 mg/d of aspirin. Higher doses negate any beneficial

anti-ischemic effect (mechanism remains unknown)


Related Documents
JOEL D. ROBBINS, MD, FACC, FSCAI · JOEL D. ROBBINS, MD, FACC, FSCAI JACK V PINTO, MD, FACC, FSCAI LISA MORAN, MSN, CNP-BC be expected to be paid off in full within 6 months of the

JOEL D. ROBBINS, MD, FACC, FSCAI · JOEL D. ROBBINS, MD,...

Category: Documents
ECG interpretation 3 DR MD TOUFIQUR RAHMAN NICVD FACC FRCP FAHA FSCAI CARDIOLOGIST

ECG interpretation 3 DR MD TOUFIQUR RAHMAN NICVD FACC FRCP.....

Category: Health & Medicine
James E. Tcheng, MD, FACC, FSCAI, FESC Professor of ...

James E. Tcheng, MD, FACC, FSCAI, FESC Professor of ...

Category: Documents
Sponsors...Deepak Bhatt MD, MPH, FACC, FAHA, FSCAI, FESC Executive Director, Interventional Cardiovascular Programs,Brighamand Women’s Hospital Heart & Vascular Center Professor

Sponsors...Deepak Bhatt MD, MPH, FACC, FAHA, FSCAI, FESC...

Category: Documents
TAVI Implantation - summitmd.comsummitmd.com/pdf/pdf/2496_EberhardGrube00000.pdf · TAVI Implantation: Rapid Pacing, Pre‐and Post Dilatation Eberhard Grube, MD, FACC, FSCAI Medi

TAVI Implantation -...

Category: Documents
ACC/AHA Guideline Revisioncirc.ahajournals.org/content/circulationaha/116/7/803.full.pdfThomas N. Levin, MD, FACC, FSCAI ; A. Michael Lincoff, MD, FACC; Eric D. Peterson, MD, MPH,

ACC/AHA Guideline...

Category: Documents
Keith Dawkins MD FRCP FACC FSCAI Chief Medical Officer Senior Vice President Boston Scientific Corporation Boston Scientific Programme Update London –

Keith Dawkins MD FRCP FACC FSCAI Chief Medical Officer...

Category: Documents
Prof. Dr. dr. Idris Idham, SpJP (K), FIHA, FACC, FESC ... · PDF fileProf. Dr. dr. Idris Idham, SpJP (K), FIHA, FACC, FESC, FASCC, FSCAI SR Negeri Tabing, Padang, Tahun 1957 SMPN Kuranji,

Prof. Dr. dr. Idris Idham, SpJP (K), FIHA, FACC, FESC ... ·...

Category: Documents
H. Arjomand, MD, FACC, FSCAI, FSVM

H. Arjomand, MD, FACC, FSCAI, FSVM

Category: Documents
DIURETIC RESISTANCE IN HEART FAILURE: Pathophysiology & Cases Discussion Bambang Budi Siswanto Prof MD, PhD, FIHA, FAsCC, FAPSC, FESC, FACC, FSCAI Dept.

DIURETIC RESISTANCE IN HEART FAILURE: Pathophysiology &...

Category: Documents
NURSE / TECHNOLOGIST SYMPOSIUM … & Structural Heart Symposium Directors Samin K. Sharma, MD, FACC, FSCAI Director, Clinical & Interventional Cardiology President, Mount Sinai Heart

NURSE / TECHNOLOGIST SYMPOSIUM … & Structural Heart...

Category: Documents
David E. Kandzari, MD, FACC, FSCAI Chief Scientific Officer Director, Interventional Cardiology Piedmont Heart Institute Atlanta, Georgia david.kandzari@piedmont.org.

David E. Kandzari, MD, FACC, FSCAI Chief Scientific Officer....

Category: Documents