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Triple antithrombotic therapy in cardiology

Triple antithrombotic therapy in cardiology. Giuseppe Biondi Zoccai Divisione di Cardiologia, Università di Torino, Ospedale San Giovanni Battista, Torino gbiondizoccai@gmail.com. Congresso Regionale A.N.M.C.O. - S.I.C. “Cuore e Dintorni” – Torino, 8/5/2009. LEARNING GOALS.

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Triple antithrombotic therapy in cardiology

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  1. Triple antithrombotictherapy in cardiology Giuseppe Biondi Zoccai Divisione di Cardiologia, Università di Torino, Ospedale San Giovanni Battista, Torino gbiondizoccai@gmail.com Congresso Regionale A.N.M.C.O. - S.I.C. “Cuore e Dintorni” – Torino, 8/5/2009

  2. LEARNING GOALS • Scope of the problem • Definition of triple antithrombotic therapy • Pros & cons • My personal choice

  3. LEARNING GOALS • Scope of the problem • Definition of triple antithrombotic therapy • Pros & cons • My personal choice

  4. MORE THAN ONE ENEMY!

  5. MORE THAN ONE ENEMY! Thromboticrisk

  6. MORE THAN ONE ENEMY! Thromboticrisk Bleedingrisk

  7. PCI WITH STENT: THE STARS TRIAL P<0.001 1965 patientsundergoing bare-metal stent implantation (Palmaz-Schatz) randomized to aspirin vs ticlopidine + aspirin vs oralanticoagulants (OA, target INR 2.0-2.5) + aspirin and followedfor 1 month – primaryend-point (death, myocardial infarction, target lesion revacsularization or angiographic stent thrombosis, 3.6% vs 0.5% vs 2.7% (p<0.001); any bleeding, 1.8% vs 5.5% vs 6.2% (p<0.001); vascular surgical complications, 0.4% vs 2.0% vs 2.0% (p=0.02) Leon et al, New Engl J Med 1998

  8. AF: THE ACTIVE TRIAL RR=1.72 (1.24-2.37) p=0.001 Clopidogrel + aspirin OA 6706 patientswithnon-valvular AF randomized to clopidogrel + 75-100 mg aspirin vs oralanticoagulants (OA, target INR 2.0-3.0) and followedfor 1.3 – early stop forsuperiority of OA; besidesreduction of stroke, no significantincrease in major bleeding (2.4% vs 2.2%, p=0.5) and significantreduction in death, infarction, stroke, or major bleeding (8.3% vs 6.5%, p=0.001) ACTIVE, Lancet 2006

  9. WHAT ABOUT CURRENT PRACTICE? Nguyen et al, Eur Heart J 2007

  10. LEARNING GOALS • Scope of the problem • Definition of triple antithrombotic therapy • Pros & cons • My personal choice

  11. TRIPLE ANTITHROMBOTIC RX • Chronic triple antithrombotic Rx encompasses several regimens: • aspirin, thienopyridine and cilostazol • aspirin, thienopyridine, and trapidil • aspirin, thienopyridine and dicoumarol/warfarin

  12. TRIPLE ANTITHROMBOTIC RX • A key aspect defining any triple antithrombotic Rx including an oral anticoagulant (OA) is target INR • Other pivotal issues are: • dosage of aspirin and thienopyridine • duration of therapy • concomitant medications (eg PPH)

  13. LEARNING GOALS • Scope of the problem • Definition of triple antithrombotic therapy • Pros & cons • My personal choice

  14. INCREMENTAL RISK OF SINGLE, DUAL AND TRIPLE ANTITHROMBOTIC RX

  15. 16 12 8 4 0 WHY USING ONLY CLOPIDOGREL AND OA: THE CAPRIE STUDY ASA 8.7%*RRreduction Clopidogrel Vasculardeath, MI, or ischemic Stroke (%) P=0.043 - N=19,185 0 3 6 9 12 15 18 21 24 27 30 33 36 Months CAPRIE, Lancet 1996

  16. DUAL VS TRIPLE RX AFTER PCI IN AF Karjalinen et al, Eur Heart J 2007

  17. IS ANY SYNTHESIS POSSIBLE OF OUTCOMES WITH TRIPLE RX? %

  18. PROS AND CONS OF ANTITHROMBOTIC RX

  19. LEARNING GOALS • Scope of the problem • Definition of triple antithrombotic therapy • Pros & cons • My personal choice

  20. STEP 1: RE-APPRAISAL OF THROMBOTIC AND BLEEDING RISK • What is the indication for OA: AF, DVT, PTE, APS, …? • What would be the appropriate duration of OA irrespective of other indications? • What is the indication for pharmacologic coronary prevention? • What is the most appropriate revascularization strategy: med Rx, POBA, BMS, DES, CABG?

  21. STEP 2: RADIAL ACCESS Agostoni et al, J Am Coll Cardiol 2004

  22. STEP 3: INDIVIDUALIZATION OF RX ON THROMBOTIC/BLEEDING RISK…

  23. …WITH MAYO SCORE FOR PCI MORTALITY… Sing et al, Circulation 2008

  24. …WITH CHADS2 SCORE FOR STROKE IN AF… Validated in a cohort study of 1,733 nonrheumatic atrial fibrillation patients aged 65 to 95 who were tracked through Medicare claims, and not given any antithrombotic therapy (either warfarin or aspirin) Cage et al, Circulation 2004

  25. …& CRUSADE SCORE FOR BLEEDING Subherwal et al, Circulation 2009

  26. …& CRUSADE SCORE FOR BLEEDING Subherwal et al, Circulation 2009

  27. TAKE HOME MESSAGES

  28. TAKE HOME MESSAGES • Careful risk-stratification of patients for thrombotic and bleeding risk is mandatory • Recommend radial access for angio/PCI • Choose other strategies (eg PCI vs CABG) coherently with antithrombotic approach • Whenever clear-cut indications exist, prescribe a regimen of lifelong 75 mg aspirin, 6-month clopidogrel, and OA with 2.0-2.5 INR target

  29. Thank you for your attention!For any correspondence: gbiondizoccai@gmail.comFor further slides on these topics feel free to visit the metcardio.org website:http://www.metcardio.org/slides.html

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