Triple thérapie anti-thrombotique chez le coronarien. Y Cottin Dijon

Transcription

1 Triple thérapie anti-thrombotique chez le coronarien Y Cottin Dijon

2 «Dans la vie, rien n est à craindre, tout est à comprendre» Marie Curie

3 Epidémiologie Aspirine/Clopidogrel/Ticagrelor/Prasugrel Durée?

4 Atrial fibrillation and acute myocardial infarction: antithrombotic therapy and outcomes 3.9% 9.2% Lopes RN, et al. Am J Med. 2012;125:

5 MI 0.72%/an (D 110) 0.9%/an(R) 0.53%/an (A) 0.74%/an (D 150) 0.53%/an (W) 1.1%/an (W) 0.51%/an (W)

6 Prognostic Impact of Types of Atrial Fibrillation in Acute Coronary Syndromes Death Lau DH et al. Am J Cardiol. 2009;104:

7 Prognostic Impact of Types of Atrial Fibrillation in Acute Coronary Syndromes Death, MI, stroke Lau DH et al. Am J Cardiol. 2009;104:

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10 Triple Therapy With Aspirin, Prasugrel, and Vitamin K Antagonists in Patients With Drug-Eluting Stent Implantation and an Indication for Oral Anticoagulation Sarafoff N, et al. JACC. 2013;61:

11 Triple Therapy With Aspirin, Prasugrel, and Vitamin K Antagonists in Patients With Drug-Eluting Stent Implantation and an Indication for Oral Anticoagulation Sarafoff N, et al. JACC. 2013;61:

12 Triple Therapy With Aspirin, Prasugrel, and Vitamin K Antagonists in Patients With Drug-Eluting Stent Implantation and an Indication for Oral Anticoagulation Sarafoff N, et al. JACC. 2013;61:

13 Triple Therapy With Aspirin, Prasugrel, and Vitamin K Antagonists in Patients With Drug-Eluting Stent Implantation and an Indication for Oral Anticoagulation Sarafoff N, et al. JACC. 2013;61:

14 Concomitant use of warfarin and ticagrelor as an alternative to triple antithrombotic therapy after an acute coronary syndrome Warfarin and ticagrelor Braun OO, et al. Thrombosis Reseach. 2015;135:26-30.

15 Concomitant use of warfarin and ticagrelor as an alternative to triple antithrombotic therapy after an acute coronary syndrome Warfarin and ticagrelor Braun OO, et al. Thrombosis Reseach. 2015;135:26-30.

16 Concomitant use of warfarin and ticagrelor as an alternative to triple antithrombotic therapy after an acute coronary syndrome Warfarin and ticagrelor Braun OO, et al. Thrombosis Reseach. 2015;135:26-30.

17 Madame X, 80 ans, FA depuis 20 ans, ATCD AIT, embolie MIG, STEMI, INR 1.9

18 Thrombolyse ou PCI AVK NACO Abord radial Dose Charge anti-aggrégants : - oui/non - Si oui lesquels? HNF Protection gastrique Bitherapie ou tritherapie Durée Long Terme

19 Management of acute coronary syndrome in patients with non-valvular atrial fibrillation: results of the EuropeanHeart Rhythm Association Survey Potpara TS, et al. Europace. 2014;16:

20 Cumulative incidence of the secondary endpoint (death, myocardial infarction, stroke, target-vessel revascularisation, and stent thrombosis) WOEST study investigators Dewilde WJ, et al. Lancet. 2013;381:

21 Incidence of the primary endpoint (any bleeding) Dewilde WJ, et al. Lancet. 2013;381:

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24 AVK NACO Thrombolyse ou PCI Oui Oui Abord radial Oui Oui Dose Charge anti-aggrégants : - oui/non - Si oui lesquels? Oui Clopidogrel Oui Clopidogrel HNF INR < 2 Relai HNF puis AVK? Protection gastrique Oui Oui Bitherapie ou tritherapie Type stent Type stent Durée Long Terme

25 Madame X, 80 ans, FA depuis 20 ans, ATCD AIT, embolie MIG, STEMI, INR 1.9 Radiale, Thrombectomie, stent

26 Que faite vous après? AVK ou ADO? Risque saignement Risque ré-idm Impact de l âge Traitements associés Aspirine oui/non Protection gastrique Capodanno d, et al. Circ Cardiovasc Interv. 2014;7:113-24

27 Antiplatelet Therapy for Stable Coronary Artery Disease in atrial Fibrillation Patients Taking an Oral Anticoagulant A Nationwide Cohort Study Lamberts M, et al. Circulation. 2014;129:

28 Antiplatelet Therapy for Stable Coronary Artery Disease in atrial Fibrillation Patients Taking an Oral Anticoagulant A Nationwide Cohort Study Lamberts M, et al. Circulation. 2014;129:

29 Antiplatelet Therapy for Stable Coronary Artery Disease in atrial Fibrillation Patients Taking an Oral Anticoagulant A Nationwide Cohort Study Major Bleeding Lamberts M, et al. Circulation. 2014;129:

30 Antiplatelet Therapy for Stable Coronary Artery Disease in atrial Fibrillation Patients Taking an Oral Anticoagulant A Nationwide Cohort Study All cause of death Lamberts M, et al. Circulation. 2014;129:

31 AOD ou AVK Schulman et al. Thromb Haemost 2014;111:575-82

32 Apixaban versus Warfarin in Patients with Atrial Fibrillation Primary Efficacy MajorBleeding Granger CB, et al. N Engl J Med,. 2011; 365:

33 A randomized, 2-period, crossover design study to assess the effects of dexlansoprazole, lansoprazole, esomeprazole, and omeprazole on the steady-state pharmacokinetics and pharmacodynamics of clopidogrel in healthy volunteers Frelinger AL, et al. J AM Coll Cardiol. 2012;59:

34 Madame X, 80 ans, FA depuis 20 ans, ATCD AIT, embolie MIG, STEMI, INR 1.9 Radiale, Thrombectomie, stent, Apixaban, aspirine, clopidogrel, pantoprazole

35 Combination of OAC plus single antiplatelet therapy (preferably clopidogrel 75 mg/day, or as an alternative, aspirin mg/day) may be sometimes continued in very selected cases, e.g. stenting of the left main, proximal left anterior descending, proximal bifurcation, recurrent MIs, etc. (Class IIb, level of evidence B).

36 RE-DUAL PCI: combination therapy in AF pts undergoing PCI Patients with NVAF undergoing PCI (n=8520) Dabigatran 150 mg BID + P2Y12 inhibitor Screening R 0 72 hours after PCI n=2840 patients per arm Dabigatran 110 mg BID + P2Y12 inhibitor Warfarin (INR ) + P2Y12 inhibitor + ASA* Minimum treatment duration: 6 months Dual primary endpoints: death, MI, stroke/se, and major bleeding *Warfarin arm: 1 month after bare metal stent or 3 months after drug-eluting stent ASA, acetylsalicylic acid; PCI, percutaneous coronary intervention Adapted from Cannon C. AHA 2013 and Boehringer Ingelheim data on file

37 GEMINI ACS 1 ACS study with single vs. dual APs Objective: Safety of Rivaroxaban in addition to either Clopidogrel or Ticagrelor in ACS Population: Diagnosis of ACS 24h Index hospitalization: 1. Acute treatment: invasive or medical management 2. Maintenance dose ASA and P2Y12 inhibitor (clopidogrel, ticagrelor) N=1,500 Clopidogrel + ASA Ticagrelor + ASA R 1:1 R Clopidogrel + Rivaroxaban 2.5 mg BID days treatment Clopidogrel + ASA Ticagrelor + Rivaroxaban 2.5 mg BID days treatment SOC 30-day follow-up SOC SOC 30-day follow-up N=1,500 1:1 Ticagrelor + ASA SOC Short design: Multicentre, prospective, randomized, double-blind, double-dummy, active-controlled, parallel-group study Indication: ACS Start: Q LPLV: Q

38 Rivaroxaban Use in Patients With AF Undergoing PCI: PIONEER AF-PCI 2100 patients with NVAF No prior stroke/tia PCI with stent placement 72 hours After Sheath removal R A N D O M I Z E Rivaroxaban15 mg qd* Clopidogrel 75 mg qd 1,6, or 12 months Rivaroxaban 2.5 mg bid Clopidogrel 75 mg qd Aspirin mg qd 1,6, or 12 months VKA (target INR ) Clopidogrel 75 mg qd Aspirin mg qd Rivaroxaban 15mg qd Aspirin mg qd VKA (target INR ) Aspirin mg qd End of treatment at 12 months Primary endpoint: TIMI major, minor, and bleeding requiring medical attention Secondary endpoint: CV death, MI, stroke, and stent thrombosis Rivaroxaban dosed at 10 mg once daily in patients with CrCl of 30 to <50 ml/min. Alternative P2Y 12 inhibitors: 10 mg once-daily prasugrel or 90 mg twice-daily ticagrelor. Low-dose aspirin ( mg/d).

39 AF + ACS/PCI Study OAC P2Y12 including ticagrelor / prasugrel ASA No ASA Apixaban 5mg BID 5 mg BID Randomizations to: 1. Apixaban or a VKA (INR ) 2. With or without ASA (all patients get a P2Y 12 antagonist) VKA therapy INR INR Academic Research Organization: Duke Clinical Research Institute (DCRI) 39

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