Carlos Augusto Bueno Silva, Dr

1. Farmacologia adjunta à Intervenção coronária percutâneaAntiplaquetários, Antitrombínicos, Hipolipemiantes Carlos Augusto Bueno Silva,Dr Serviço de Hemodinâmica e Cardiologia Intervencionista do Hospital São João de Deus – Divinópolis Sem conflito de interesses.

2. Antiplaquetários • Aspirina • Ticlopidina • Clopidogrel • Prasugrel • Cilostazol • Inibidores 2b3a

3. Aspirina

4. Inibição da ativação plaquetária

5. Eficácia da Aspirina x Dose

6. CURE – Sangramento maior – Dose de aspirina – 1 ano

7. Aspirina no IM agudo ISIS-2 ISIS 2 Lancet 1988;2:349-60

8. Tienopiridínicos

9. Eficácia da antiagregaçãoplaquetária dupla na redução de eventos coronarianos pós Stents

10. Equivalência entre Ticlopidina e Clopidogrel

11. Dose de ataque de 300mg x placebo

12. Momento ideal – dose 300mg

13. Dose de 600 mg é superior ?

14. ARMYDA - 2

15. ARMYDA-2 Eventos Hemorrágicos

16. The ISAR-REACT trial evaluated the efficacy of abciximab in 2159 patients undergoing elective percutaneous coronary intervention (PCI) . All patients were pretreated with 600 mg of clopidogrel at least two hours before PCI. When the study subjects were grouped into four subsets based upon duration of clopidogrel pretreatment (2 to 3 hours, 3 to 6 hours, 6 to 12 hours, and >12 hours), there was no significant difference among the four groups in the incidence of death, MI, or urgent revascularization at 30 days or in the rate of major bleeding.

17. OASIS 7

19. Absorption, metabolization, and antiplatelet effects of 300-, 600-, and 900-mg loading doses of clopidogrel: results of the ISAR-CHOICE (Intracoronary Stenting and Antithrombotic Regimen: Choose Between 3 High Oral Doses for Immediate Clopidogrel Effect) Trial. von Beckerath N, Taubert D, Pogatsa-Murray G, Schömig E, Kastrati A, Schömig A Circulation. 2005;112(19):2946. ).CONCLUSIONS: Single doses of clopidogrel higher than 600 mg are not associated with an additional significant suppression of platelet function because of limited clopidogrel absorption.

20. The ARMYDA-4 RELOAD study involved 503 patients already taking chronic clopidogrel who required PCI. They were randomized to a 600-mg clopidogrel loading dose four to eight hours before PCI or placebo. The primary end point was death, MI, or target vessel revascularization at 30 days. In the overall population, this was slightly reduced in the loading-dose group but not significantly so. But those patients with ACS (about 40% of the trial population) did show a better outcome when given the additional loading dose. There was no excess bleeding in the reload arm (6% in both groups).

27. Balanço entre eficácia e segurança

28. Diabéticos ( n= 3.146 )

29. Trombose de Stent

30. Subgrupos com risco de sangramento

31. Inibidores GP2b3a

32. Redução de Morte, IM, nova RM, eventos combinados – 30 dias

33. Redução de morte, IM, Nova RM, eventos combinados – 6 meses

34. GP2b3a – Benefício em pctes de maior risco

35. Cilostazol – Efeitos farmacológicos

36. Antitrombínicos • Heparina não fracionada • Heparina de baixo peso molecular • Inibidores diretos da trombina • Fondaparinux

37. Heparina Não fracionada

39. HNF – Vantagens x Desvantagens

40. Enoxaparian x HNFMorte ou IM em 30 dias

43. Enoxaparina em ICP trials

44. Bivalirudina

45. Bivalirudina não inferior a HNF/IGP2b3a

46. Fondaparinux OASIS 5 - Resultados CSA de alto risco ( VS enoxaparina) Similar eficácia, menor sangramento Necessidade de HNF suplementear para ICP

47. Obrigado!