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CARDIOPATIA ISCHEMICA

Progetto Formativo ANMCO - AIAC UNIVERSO TROMBOSI ROMPERE IL LEGAME TRA FIBRILLAZIONE ATRIALE & ICTUS CONSIGLI D’AUTORE. CARDIOPATIA ISCHEMICA. 25 febbraio 2014 In collegamento con: Torino, Bergamo, Mestre, Bologna, Lucca, Roma, Napoli, Bari, Catania, Cagliari.

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CARDIOPATIA ISCHEMICA

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  1. Progetto Formativo ANMCO - AIAC UNIVERSO TROMBOSI ROMPERE IL LEGAME TRA FIBRILLAZIONE ATRIALE & ICTUS CONSIGLI D’AUTORE CARDIOPATIA ISCHEMICA 25 febbraio 2014 In collegamento con: Torino, Bergamo, Mestre, Bologna, Lucca, Roma, Napoli, Bari, Catania, Cagliari

  2. NAO e Cardiopatia IschemicaLe Questioni Aperte • I NAO sono tutti uguali rispetto al rischio coronarico ? • Quando impiegare i NAO nei pazienti con Cardiopatia Ischemica ?

  3. Mak K-H. Coronary and mortality risk of novel oral antithrombotic agents: a meta-analysis of large randomised trials. BMJ Open 2012;2:e001592.

  4. Mak K-H. Coronary and mortality risk of novel oral antithrombotic agents: a meta-analysis of large randomised trials. BMJ Open 2012;2:e001592.

  5. Mak K-H. Coronary and mortality risk of novel oral antithrombotic agents: a meta-analysis of large randomised trials. BMJ Open 2012;2:e001592.

  6. Rischio di Infarto nei Pazienti in terapia con NAO • Meta-analisi di 28 RCTs, per un totale di 138 948 pazienti. • Il rischio di IMA/SCA è risultato significativamente più elevato per il Dabigatran, (OR 1.30; 95% CI 1.04 to 1.63; p=0.021), mentre risulta significativamente ridotto per il Rivaroxaban (OR 0.78; 95% CI 0.69 to 0.89; p<0.001). • Non sono state rilevate significative interazioni per Apixaban. Mak K-H. Coronary and mortality risk of novel oral antithrombotic agents: a meta-analysis of large randomised trials. BMJ Open 2012;2:e001592.

  7. Management of Patients with CAD ad AF • The challenge in the management of patients with concomitant CAD and AF arises because single or dual antiplatelet therapies are the preferred therapiesfor the prevention of coronary events and OAC is the preferred therapy for prevention of all stroke in AF. • Antiplatelet and OAC agents might both be required to prevent coronary events and stroke, but will increase the risk of major bleeding. • In the absence trials including patients with both CAD and AF, guidelines for their management have been derived from logical extrapolations from studies comparing antithrombotic therapies among patients with either CAD or AF, and using observational data from patients receiving a variety of antithrombotic regimens for the management of CAD and AF 2013 EHRA PRACTICAL GUIDE for NOACs, Europace (2013) 15, 625–651

  8. Focused 2012 Update of the Canadian Cardiovascular Society AF Guidelines Canadian Journal of Cardiology 28 (2012) 125–136

  9. North American Consensus on Antithrombotic Therapy in patients with AF undergoing PCI Circ Cardiovasc Interv. 2011;4:522-534

  10. North American Consensus on Antithrombotic Therapy in patients with AF undergoing PCI • Low-dose (100 mg) aspirin should be used. • Gastric acid suppressing agents to reduce GI bleeding, preferably a PPI, should be given. • Clopidogrel is the thienopyridine of choice in combination with aspirin and warfarin. • Prasugrel and ticagrelor cannot be recommended with warfarin until the safety of such triple therapy is demonstrated given the increased bleeding associated with these agents. • Warfarin should be dose adjusted and closely monitored to maintain the INR between 2 and 2.5. Circ Cardiovasc Interv. 2011;4:522-534

  11. Use of clopidogrel with or without aspirin in patients taking OAC therapy and undergoing PCI: an open-label RCT Incidence of the secondary endpoint (death, , stroke, MI, target-vessel revascularisation, and stent thrombosis) Incidence of the primary endpoint (any bleeding) 573 patients were enrolled and 1-year data were available for 279 (98·2%) patients assigned double therapy (clopidogrel + warfarin) and 284 (98·3%) assigned triple therapy (ASA + clopidogrel + warfarin). The WOEST Investigators, Lancet 2013; 381: 1107–15

  12. Triple Therapy With Aspirin, Prasugrel, and VKAs in Patients With DES Implantation and an Indication for Oral Anticoagulation Composite of TIMI major and minor bleeding Composite of dath, MI, stroke and stent thromosisi Consecutive series of 377 patients who underwent DES implantation and had an indication for oral anticoagulation and were treated with a 6-month regimen of aspirin and oral anticoagulation with either prasugrel or clopidogrel. Twenty-one patients (5.6%) received prasugrel instead of clopidogrel. TIMI major and minor bleeding occurred significantly more often in the prasugrel compared with the clopidogrel group Sarafoff N, JACC 2013; 61: 2060–6

  13. Oral Anticoagulation and Antiplatelets in Atrial Fibrillation Patients After MI and PCI: data from the Danish National Patient Registry A total of 12,165 AF patients hospitalized with MI and/or undergoing PCI between 2001 and 2009 were identified by nationwide registries (60.7% male; mean age 75.6 years). Risk of MI/coronary death, ischemic stroke, and bleeding according to antithrombotic treatment regimen was estimated by Cox regression models. In real-life AF patients with indication for multiple antithrombotic drugs after MI/PCI, OAC and clopidogrel was equal or better on both benefit and safety outcomes compared to triple therapy Lamberts M, JACC 2013; 62:981-9

  14. Anticoagulation in patients with prior MI • Stable patients with prior MI developing AF should receive anticoagulation, depending on their CHA2DS2-VASc score. • Since VKAs alone are superior to aspirin post-MI, and VKAs + ASA may not be more protective but associated with excess bleeding, anticoagulation with VKAs without additional antiplatelet agents is considered sufficient for most AF stable patients with prior MI. 2013 EHRA PRACTICAL GUIDE for NOACs, Europace (2013) 15, 625–651

  15. Anticoagulation in patients with prior MI • About 15–20% of patients in the three Phase 3 NOAC AF trials had a prior MI. • No interaction in terms of outcome or safety was observed between patients with or without a prior MI, although it is unclear in how many patients antiplatelet therapy was maintained and for how long. • It is likely that the advantages of NOACs (in monotherapy) over VKAs are preserved in CAD patients with AF. 2013 EHRA PRACTICAL GUIDE for NOACs, Europace (2013) 15, 625–651

  16. Anticoagulation in patients with prior MI 2013 EHRA PRACTICAL GUIDE for NOACs, Europace (2013) 15, 625–651

  17. Conclusioni • Nei pazienti con Cardiopatia Ischemica cronica stabile i NAO sono una valida alternativa al Warfarin ed è preferibile l’impiego di inibitori del fattore Xa. • Nei pazienti con SCA e/o PCI il Warfarin è ancora l’anticoagulante di scelta. Inoltre, in questi pazienti, recenti evidenze sembrano indicare che è preferibile l’associazione con il solo Clopidogrel, piuttosto che la triplice terapia di combinazione, ovvero l’uso dei nuovi anti-aggreganti (Prasugrel).

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