La combinazione antitrombotica appropriata nel paziente

ANDREA RUBBOLI
Unità Operativa di Cardiologia
Laboratorio di Cardiologia Interventistica
Ospedale Maggiore
Bologna
La combinazione antitrombotica
appropriata nel paziente con fibrillazione
atriale e indicazione alla TAO sottoposto ad
angioplastica coronarica con impianto di
stent
Go, A. S. et al. JAMA 2001;285:2370-2375.
DISCLOSURES
Lecture honoraria and/or research grant
and/or consulting:
Astra Zeneca
Bayer Healthcare
Boehringer Ingelheim
Daiichi Sankyo
Pfizer-BMS
Go, A. S. et al. JAMA 2001;285:2370-2375.
OAC vs. DAPT
Stroke
The ACTIVE Investigators. Lancet 2006;367:1903-12
Subacute stent thrombosis
Bertrand ME et al. Circulation 1998;98:1597-1603
Go, A. S. et al. JAMA 2001;285:2370-2375.
QUESTIONS
1. OAC + 1 or 2 antiplatelets?
clopidogrel or
2.
prasugrel/ticagrelor?
3. warfarin or NOAC?
Go, A. S. et al. JAMA 2001;285:2370-2375.
RECOMMENDATIONS:
1. Triple therapy of OAC,
aspirin, and clopidogrel (Class
IIa; LOE C)
Lip GY et al. Eur Heart J 2014;35:3155-79
Go, A. S. et al. JAMA 2001;285:2370-2375.
Safety and efficacy of triple antithrombotic therapy after
percutaneous coronary intervention in patients needing long-term
anticoagulation
Vitamin K-antagonists
Singh PP et al. Ther Adv Cardiovasc Dis 2011;5:23-31
Go, A. S. et al. JAMA 2001;285:2370-2375.
Bleeding avoiding strategies
1
reduced intensity of OAC (i.e., target INR 2.0-2.5)
2.
reduced duration of triple therapy (i.e., 1 to 3-6
months)
3.
routine use of gastric protection (i.e., PPIs)
Go, A. S. et al. JAMA 2001;285:2370-2375.
Use of clopidogrel with or without aspirin in patients taking oral anticoagulant
therapy and undergoing percutaneous coronary intervention: an open-label,
randomised, controlled trial
1° endpoint – Safety
(total bleeding)
2° endpoint - Efficacy
(stroke, death, MI, re-PCI/CABG, stent thrombosis)
Dewilde WJ et al. Lancet 2013;381:1107-15
Go, A. S. et al. JAMA 2001;285:2370-2375.
Sicurezza
• differenza trascinata da emorragie clinicamente non maggiori
• eccesso di emorragie vs. Letteratura/pianificazione dello studio
Efficacia
• differenza trascinata da mortalità non-cardiaca
• sottodimensionamento per identificare differenze di trombosi di stent
• incertezza nei pazienti con “resistenza” al clopidogrel
Rubboli A, Limbruno U. G Ital Cardiol 2013;14:564-8
Go, A. S. et al. JAMA 2001;285:2370-2375.
RECOMMENDATIONS:
1. Triple therapy of OAC, aspirin,
and clopidogrel (Class IIa; LOE C)
2. Dual therapy of OAC, and
clopidogrel (Class IIb; LOE C)†
† selected pts. at high bleeding risk
and low risk of stent
thrombosis/recurrent ischemic events
Lip GY et al. Eur Heart J 2014;35:3155-79
Go, A. S. et al. JAMA 2001;285:2370-2375.
Triple therapy of VKA + aspirin + clopidogrel/prasugrel after PCI
HR 4.6 (95% CI 1.9-11.4; p<0.001)
HR 1.4 (95% CI 0.3-6.1; p= 0.61)
Sarafoff N et al. J Am Coll Cardiol 2013;61:2060-6
Go, A. S. et al. JAMA 2001;285:2370-2375.
NOACs in AF + PCI
PIONEER-AF PCI
RE-DUAL PCI
Rivaroxaban 15mg OD +
clopidogrel/ticagrelor/prasugrel
Dabigatran 110 mg BID +
clopidogrel/ticagrelor
vs
vs
Rivaroxaban 2.5mg BID +
clopidogrel/ticagrelor/prasugrel + ASA
Dabigatran 150mg BID +
clopidogrel/ticagrelor
vs
vs
Warfarin (INR 2.0-3.0) +
clopidogrel/prasugrel/ticagrelor + ASA
Warfarin (INR 2.0-2.5) +
clopidogrel/ticagrelor + ASA
Gibson CM et al. Am Heart J 2015;169:472-8
www.http//clinicaltrials.gov/ct2/show. Accessed August 14, 2014
Go, A. S. et al. JAMA 2001;285:2370-2375.
Concomitant Use of Antiplatelet Therapy with Dabigatran or Warfarin in the
Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY®) Trial
RR of major bleed vs OAC alone:
OAC* + SAPT: 1.6
OAC* + DAPT: 2.3
* irrespective of the oral
anticoagulant (warfarin, dabigatran
110 or dabigatran 150)
Dans
Dans AL
AL et
et al.
al. Circulation
Circulation 2013;127:634-40
2013;127:634-40
Go, A. S. et al. JAMA 2001;285:2370-2375.
Viewpoint: a proposal for a simple algorithm for managing oral anticoagulation
and antiplatelet therapy in patients with non-valvular atrial fibrillation and
coronary stents
Steg PG, Bhatt DL. Eur Heart J Acute Cardiovasc Care 2015;
epub ahead of print
Go, A. S. et al. JAMA 2001;285:2370-2375.
CONCLUSIONI
Nel paziente in TAO sottoposto a PCI con stent:
1. la combinazione antitrombotica (iniziale) appropriata è generalmente TT*
2. la DT** può essere considerata in casi selezionati
3. vanno sempre implementate misure per ridurre l’aumentato rischio emorragico
4. i nuovi anticoagulanti orali potrebbero rappresentare la TAO da preferire
* OAC (con anticoagulante in corso) + aspirina + clopidogrel; ** OAC (con anticoagulante in corso) +
clopidogrel
Go, A. S. et al. JAMA 2001;285:2370-2375.