ème Réunion Nationale du GRCI, Tous droits réservés - Toute reproduction même est interdi
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1 GRCI Dec 2014 Quel Anticoagulant Oral dans le SCA avec FA? oute repr ème Réunio du Goute reproduction même est interdi E. FERRARI Service de cardiologie. CHU Nice ème Réunio du Goute reprodt inte
2 25% des FA 5% des SCA Coronaropathie et FA Trithérapie = Triple risque hémorragique oute repr ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
3 Les grands principes les AVK n évitent pas la thrombose de stent oute repr ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
4 oute repr Héparine Aspirine & Ticlopidine ISAR Schomig et al: N Engl J Med Stenting Randomisation ème Réunio du Goute reproduction même est interdi Héparine Aspirine AVK 1.6% End points 6.2% 0 Stent thrombosis 5% ème Réunio du Goute reprodt inte
5 Les grands principes les AVK n évitent pas la thrombose de stent oute repr Mais on peut difficilement s en passer pour la FA ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
6 Traitement anti-thrombotique chez tous les autres oute repr ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
7 oute repr SCA et FA Bithérapie antiagrégante sans Anticoagulant Oral? ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
8 ESC 2014 Revascularisation myocardique DAPT should be considered as alternative to initial triple therapy for patients with Stable CAD and AF with a CHAD2DS2-VASc score 1 oute repr ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
9 ESC 2014 Revascularisation myocardique DAPT should be considered as alternative to initial triple therapy for patients with Stable CAD and AF with a CHAD2DS2-VASc score 1 oute repr ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
10 Risk factor-based point-based scoring system - CHA 2 DS 2 -VASc CHADs VASC2 < 1 chez un patient coronarien en FA? oute repr ème Réunio du Goute reproduction même est interdi *Prior myocardial infarction, peripheral artery disease, aortic plaque. Actual rates of stroke in contemporary cohorts may vary from these estimates. European Heart Journal (2010) 31, ème Réunio du Goute reprodt inte
11 ESC 2014 Revascularisation myocardique DAPT should be considered as alternative to initial triple therapy for patients with Stable CAD and AF with a CHAD2DS2-VASc score 1 oute repr ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
12 (N)ACO 1 AAP 2 AAP (N)ACO 1 AAP 2 AAP SCA & FA On peut raccourcir la bithérapie voire la discuter mais jamais s affranchir d un ACO oute repr SCA en FA: CHADsVASc 2 & HAS BLED 2: SCA et FA: CHADsVASc 2 HAS BLED ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
13 ESC 2014 Revascularisation myocardique (N)OAC (N)OAC (N)OAC (N)OAC (N)OAC oute repr ème Réunio du Goute reproduction même est interdi (N)OAC (N)OAC (N)OAC ème Réunio du Goute reprodt inte
14 oute repr NACO à la place des AVK Arguments en faveur ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
15 oute repr ème Réunio du Goute reproduction même est interdi AVC 19% RRR Mortalité globale 10% RRR Saignts Graves 14% RRR HIC 61% RRR ème Réunio du Goute reprodt inte
16 Dabi 110 x 2 sans AAP Dabi 110 x 2 avec AAP Dabi 150 x 2 Sans AAP Dabi 150 x 2 avec AAP Warfarine sans AAP Warfarine avec AAP Dabigatran + AAP dans RELY Saignements majeurs oute repr ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
17 oute repr NACO à la place des AVK Arguments en défaveur ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
18 % Evts On perd l effet protecteur de l AVK sur les coronaires. Evt Ischémiques card fatals Warfarine Années suivi P=0.003 % Evts Evt Ischémiques card fatals Aspirine oute repr ème Réunio du Goute reproduction même est interdi Années suivi Medical Research Council. Lancet 1998; 351: P= ème Réunio du Goute reprodt inte
19 Etudes coronaires des NACO ETUDES Phase n DC/IdM/AVC NACO vs standard RE-DEEM (Dabigatran) APPRAISE (Apixaban) ATLAS TIMI 51 (Rivaroxaban) Saignements NACO vs standard II % vs 3.8% Sur-risque % vs 2.2% oute repr ème Réunio du Goute reproduction même est interdi III % vs 7.9% Sur-risque % vs 0.5% III % vs 10.7% * Sur-risque % vs 0.6% * Pas la dose de la FA ème Réunio du Goute reprodt inte
20 Risk of myocardial infarction and acute coronary syndrome across 7 studies, including original Randomized Evaluation of Long-term Anticoagulant Therapy (RE-LY) results oute repr Copyright restrictions may apply. 33% de sur- risque coronarien ème Réunio du Goute reproduction même est interdi Uchino, K. et al. Arch Intern Med 2012;0:archinternmed v1-6. Avec un atcd avec le Ximelagatran ème Réunio du Goute reprodt inte
21 Clinical study: rivaroxaban and PCI in AF (PIONEER AF-PCI) study design Randomized, open-label, multicentre study Objective: To assess the safety of two rivaroxaban treatment strategies and a dose-adjusted vitamin K antagonist (VKA) treatment strategy after percutaneous coronary intervenion (PCI) (with stent placement) in subjects with non-valvular atrial fibrillation (AF) Study population: Patients with paroxysmal, persistent or permanent AF, who have undergone a PCI (with stent placement) *ASA ( mg daily) + clopidogrel (75 mg daily) # CrCl ml/min: 10 mg od First dose administered hours after sheath removal First dose administered hours after sheath removal Participating countries: Argentina, Belgium, Canada, Chile, Denmark, France, Germany, Italy, Netherlands, Poland, Russia, Sweden, UK, USA N= R 1:1:1 Rivaroxaban 2.5 mg bid + DAPT* Rivaroxaban 15 mg od # + clopidogrel oute repr ème Réunio du Goute reproduction même est interdi VKA (INR ) + DAPT* Intended DAPT duration of 1, 6 or 12 months Rivaroxaban 15 mg od # + low-dose ASA VKA + low-dose ASA End of treatment (12 months) Primary endpoint: Safety: Composite of TIMI major bleeding, minor bleeding and bleeding requiring medical attention (known collectively as clinically significant bleeding) events Study milestones: FPFV: May 1 st 2013 LPLV: 30 Aug 2015 CSR: 30 Dec 2015 ASA, acetylsalicylic acid; CrCl, creatinine clearance; DAPT, dual antiplatelet therapy; DB, database lockdown; FPFV, first patient first visit; od, once daily; LPLV, last patient last visit; TIMI, Thrombolysis in Myocardial Infarction ème Réunio du Goute reprodt inte
22 DUAL-PCI Trial design Paroxysmal, persistent or permanent AF, PCI with stenting [BMS or DES] elective or ACS Screening Patients 80 years living outside of the USA will be assigned to 110mg dabigatran etexilate (BID) or warfarin in a 1:1 ratio R 0-72 hours post-pci n = approximately 2840 patients per arm (Total = approximately 8520 patients) 1 End Point Time to death or first thrombotic event (all death, MI, stroke/se) plus Time to first major bleeding event (ISTH Major) Dabigatran etexilate 150 mg BID + P2Y12 inhibitor Dabigatran etexilate 110 mg BID + P2Y12 inhibitor oute repr ème Réunio du Goute reproduction même est interdi Warfarin (INR ) + P2Y12 inhibitor + ASA DE arms: ASA ( 100 mg) discontinuation immediately after PCI Warfarin arm: ASA discontinuation after 1 month (BMS) or 3 months (DES) P2Y12 inhibitor (clopidogrel 75 mg qd or ticagrelor 90 mg bid) can be discontinued after 12 months of follow up at the discretion of the investigator ème Réunio du Goute reprodt inte
23 ESC 2014 Revascularisation myocardique L utilisation de Ticagrelor ou de Prasugrel dans une trithérapie n est pas recommandée III C oute repr ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
24 Quoi qu il en soit le NACO ne peut se concevoir que pour une FANV (ou une EP) FA non valvulaire Embolie Pulmonaire FA valvulaire Thrombus VG Large akinésie antérieure OUI OUI NON oute repr ème Réunio du Goute reproduction même est interdi NON NON ème Réunio du Goute reprodt inte
25 oute repr ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
26 ESC 2014 Revascularisation myocardique oute repr ème Réunio du Goute reproduction même est interdi ème Réunio du Goute reprodt inte
27 Anticoagulant ou pas d anticoagulant? Regarder le risque embolique de la FA oute repr si CHADsVASc 2 Anticoagulant recommandés ème Réunio du Goute reproduction même est interdi I C Si CHADsVASc 1 DAPT sans Anticoagulants IIa C ème Réunio du Goute reprodt inte
28 Saignements majeurs Triple thérapie anti-thrombotique Aspirine + Prasugrel + AVK Asp + Prasu + AVK (n=21) oute repr ème Réunio du Goute reproduction même est interdi Asp + Clopi +AVK (n=356) 28.6% 6.7% Sarafoff N et al JACC ème Réunio du Goute reprodt inte
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