2
EuroPCR
Six to 12 months is the right timeframe for dual
antiplatelet therapy Continued from page 1
everolimus-eluting stent (Xience) allowing DAPT to be stopped, respectively, after one and three months. He said: “I think there has been a slight miscommunication about these changes. The studies behind them reviewed interruption of treatment; they did not evaluate planned discontinuation of treatment. So unless we have definitive trial data that shows planned discontinuation of one month or three months is safe, I do not think we can to stop at this time. However, I am now much more comfortable with stopping DAPT in patient with a new stent who has a bleed at three or four months or who needs an operation.”
Choice of antiplatelets
As well as discussing second-generation drug-eluting stents, the speakers at the debate also reviewed the use of new antiplatelets (ie. prasugrel or ticagrelor). Ibrahim Al Rashdan (Kuwait Heart Center, Chest Hospital of Kuwait, Kuwait City, Kuwait) said: “New antiplatelet therapies add value to our existing armamentarium in the cath lab. We do not have prasugrel in the Middle East but we do have ticagrelor, and we found that patients who were treated with ticagrelor had less stent thrombosis and less mortality. Therefore, in this particular case [ie. the aforementioned stable patient with left main disease], I would definitely use ticagrelor and aspirin. If cost is an
Ibrahim Al Rashdan
not. He said: “Who is the patient? What are their risk factors? Is he diabetic? What is the size and length of the stent that you will be using? Our role is to take everything into consideration when choosing antiplatelet therapy.” Lotan added that he would use one of the new antiplatelets in patients who had a higher degree of stenosis even if they were stable.
Responding to a question about how he would treat a
Who is the patient? What are their risk factors? Is he diabetic? What is the size and length of the stent that you will be using? Our role is to take everything into consideration when choosing antiplatelet therapy
issue, as the greatest benefit of new antiplatelets is seen in the first month, you could use ticagrelor for a month and then switch to clopidogrel.”
Chaim Lotan (Hadassah-Hebrew University Medical
Center, Jerusalem, Israel) noted that individual patient characteristics had to be taken into consideration when choosing whether to use a new antiplatelet or
superiority over heparin Continued from page 1
bivalirudin and less GPIIb/IIIa inhibitors. But, the majority of patients receive heparin alone.” Furthermore, according to Angerås, there are no modern studies that compare heparin alone vs. bivalirudin in this group of patients.
Angerås said: “The purpose of our study was to compare the outcome of heparin alone versus bivalirudin in patients with NSTE-ACS undergoing PCI between 2005 and 2011 and registered in SCAAR. The primary endpoint was 30-day mortality.” He and his co-authors identified 41,537 patients in the registry with NSTE-ACS who were not receiving GPllb/IIIa inhibitors, but data were missing for 6,006 patients. Thus, they performed two analyses: a complete analysis (26, 841
patients on heparin alone vs. 8,690 on bivalirudin) and an imputed data analysis (missing data imputed by a multiple imputation model; 31,351 patients on heparin alone vs. 10,186 on bivalirudin). Angerås commented that at baseline, there were no significant differences between the patient groups, adding: “Over 90% of patients received preloading clopidogrel (Plavix, Bristol- Myers Squibb) and 70% of patients were biomarker positive. Also, almost 50% of patients underwent PCI through the radial approach and almost 22% of patients receiving bivalirudin received heparin during the procedure.” In both the complete case model and the imputed case model, the 30-day mortality rate seem to favour heparin (ie, it
patient who was allergic to aspirin, Baumbach reported: “The first thing to ask is it a true allergy? Can we re- expose them to aspirin and see if something happens? If it was a true allergy and the patient was operable, I would swing towards surgery. It is too much of a risk to put a patient onto a treatment regimen (ie. without aspirin) that might not be anti-ischaemic enough.”
Questions raised about bivalirudin’s Robert Byrne
However, he added that the concept of monotherapy would emerge into the next two or three years, saying: “We will not be talking about prasugrel or ticagrelor plus aspirin; we will be talking about prasugrel or ticagrelor alone and that would solve the problem of patients who cannot take aspirin.”
Lotan stated that while the additional benefit of the aspirin was small, “no one wants to do a study without it.” He added: “I suspect with the new antiplatelets, the additional benefit of aspirin is very small and when people ask which treatment should be stopped first with triple therapy, definitely aspirin could be stopped.”
The unstable patient
The panel also discussed managing patients with ST- segment elevation myocardial infarction (STEMI). Christoph Naber (Contilia Heart and Vascular Center, Essen) commented: “If it is a STEMI patient, everything changes as we now have a life-threatening event. We do not need to think about stent thrombosis at first as the more important thing is to reduce recurrent events.” The panel was chaired by Martyn Thomas (St Thomas’ Hospital, London, UK) and Michael Haude (Städtische Kliniken Neuss, Lukaskrankenhaus GmbH, Dusseldorf, Germany).
and bivalirudin, but stated they did not have any specific data on bleeding (ie. they did not know the type of bleeding that occurred).
Concluding, Angerås reported: “Our large
Oskar Angerås
was slightly reduced). However, Angerås said: “When we used the instrumental variable to adjust for the unknown confounders, we could see no difference between bivalirudin and heparin. We also looked at subgroups (age, gender, diabetes, access site, and year of procedure) and did not find any positive interaction (ie. neither drug was superior in any of the subgroups).”
He added they did not find a significant difference in the rate of bleeding between heparin
observational study questions the superiority of bivalirudin over heparin in the absence of GPIIb/IIIa blockade in patients with NSTE-ACS undergoing PCI.”
Angerås reported that a prospective randomised trial evaluating heparin vs. bivalirudin was “highly warranted” and that he and his colleagues had already initiated the “VALIDATE- SWEDEHEART” study. He explained that in this study, both ST-elevation myocardial infarction (STEMI) and non- STEMI (NSTEMI) patients will be randomised to receive heparin or bivalirudin. All patients will be pretreated with adenosine diphosphate (ADP)-
receptor blockade. Angerås commented: “The primary outcome is death, myocardial infarction or major bleeding at 180 days.” Additionally, a parallel study—REAL- SWEDEHEART—will evaluate the radial approach with the femoral approach in STEMI patients.
Angerås told Cardiovascular
News that using heparin alone in the setting of NSTE- ACS was not a guideline- recommended therapy but added: “Our report does not require an urgent adoption to guidelines [ie. use heparin with GPllb/IIIa inhibitors/ use bivalirudin] and as long as there are no randomised trials pointing in another direction, the usage of heparin alone can continue. At least in my department, the usage of heparin alone instead of bivalirudin has enabled us to reallocate money to other more prioritised areas.”
August 2013
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