The international newspaper for cardiovascular specialists


Bernhard Meier: PFO closure


Page 8


Six to 12 months is the right timeframe for dual antiplatelet therapy


During the Great Debate at this year’s EuroPCR (21–24 May, Paris, France), leading experts in interventional cardiology discussed the use of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). The key issues raised were the optimum duration of DAPT with second-generation, drug-eluting stents and the use of new, more potent, antiplatelets


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he focus of the discussion was how the speakers would manage a stable patient with evidence of a tight distal stenosis in the left main artery. Robert Byrne (Deutsches Herzzentrum Munchen, Berlin, Germany) said that the European Society of Cardiology (ESC) recommended that DAPT (with aspirin and clopidogrel) be continued for six to 12 months in stable patients who have undergone PCI with a drug-eluting stent. He added: “I think that, probably, we will never have a randomised controlled trial that definitively tells us which subset of patients should receive DAPT for six months and which subset should receive it for 12 months. We have to look at the risks of bleeding vs. the risk of stent thrombosis. Unfortunately, risk factors


for bleeding and those for stent thrombosis tend to cluster on the same patient; therefore, a patient who has a high risk of bleeding may also have a high risk of stent thrombosis. At the end of the day, it comes down to your clinical judgement.”


Andreas Baumbach, Bristol Heart Institute, Bristol, UK, added that the CURE (Clopidogrel in unstable angina to prevent recurrent events) study was the reason why guidelines—and many interventional cardiologists—


recommended that DAPT should be continued up to 12 months in patients with non-ST segment elevation myocardial infarction (NSTEMI) acute coronary syndromes. He said: “If you look at the data from CURE, you see that the curves between DAPT and single therapy after PCI keep separating. So there is at least an anti-ischaemic benefit of prolonging DAPT to 12 months. The CURE investigators stopped at 12 months, which is why we stop at 12 months.” Baumbach commented that he would continue to recommend DAPT for six to 12 months in patients who had received a second-generation drug-eluting stent. Recently, after new data were published, the CE marking changed for both Medtronic’s zotarolimus- eluting stent (Resolute) and Abbott Vascular’s Continued on page 2


Chaim Lotan: Profile


Page 20


August 2013 Issue 30


Erwin Blessing: Renal denervation


Page 24


Questions raised about bivalirudin’s superiority over heparin


Results from the Swedish coronary angiography and angioplasty registry (SCAAR) indicate that there is no difference in the rate of 30-day mortality between bivalirudin and heparin in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) undergoing percutaneous coronary intervention (PCI)—questioning the supposed superiority of bivalirudin over heparin in this patient group


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n a late-breaking trial session at EuroPCR (21–24 May, Paris, France), lead author Os- kar Angerås (Department of Cardiology, Sahlgren- ska University Hospital, Gothenburg, Sweden) reported that he and his fellow investigators used data from SCAAR to as- sess the outcome of using heparin alone compared with outcome of using bivalirudin (Angiox, The Medicines Company) in patients with NSTE- ACS.


He explained the current view that bivalirudin was the “treatment of choice” was based on data from the ACUITY (Acute catheterization and urgent intervention triage


strategy) study, which showed bivalirudin alone to significantly reduce the risk of major bleeding compared with heparin plus glycoprotein (GP)IIb/IIIa inhibitors in patients with moderate or high-risk acute coronary syndromes undergoing invasive treatment. However, Angerås added: “Less than 60% of patients in the ACUITY study were biomarker positive, less than 60% underwent PCI, and the radial approach was used in only 6.2% of patients undergoing PCI, which is quite different from our clinical practice. Since 2006 [when the ACUITY study was published], we have used more


Continued on page 2


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