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8/3/2019 ESC Congress 2011
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Prof. Dr. med. Sigmund SilberFACC, FESC
Cardiology Practice and HospitalMunich, Germany
Outpatient Practice Heart Center at the Isar
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10th Anniversaryof CCP !
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1. Impressions and General Informations
2. Update on Indications for Revascularization
3. Update on Drug-Eluting Stents
4. Update on new Oral Anticoagulation in ACS
5. Update on new Oral Antiplatelet Drugs in ACS
- Take Home Messages for Practitioners -Coronary Artery Disease
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1. Impressions and General Informations
2. Update on Indications for Revascularization
3. Update on Drug-Eluting Stents
4. Update on new Oral Anticoagulation in ACS
5. Update on new Oral Antiplatelet Drugs in ACS
- Take Home Messages for Practitioners -Coronary Artery Disease
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- Take Home Messages for Practitioners -Coronary Artery Disease (CAD)
Sources for the Messages:
Hot Lines / Clinical Trial Updates / Clinical Registry Highlights
New Guidelines
Preorganized Sessions Original Contributions (oral presentations / posters)
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- Take Home Messages for Practitioners -Coronary Artery Disease (CAD)
Sources for the Messages:
Hot Lines / Clinical Trial Updates / Clinical Registry Highlights
Drugs /
Epidemiology
Rhythm PCI Valvular
n = 23 n = 9 n = 5 n = 2
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- Take Home Messages for Practitioners -Coronary Artery Disease (CAD)
Sources for the Messages:
Hot Lines / Clinical Trial Updates / Clinical Registry Highlights
New Guidelines
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1. Impressions and General Informations
2. Update on Indications for Revascularization
3. Update on Drug-Eluting Stents
4. Update on new Oral Anticoagulation in ACS
5. Update on new Oral Antiplatelet Drugs in ACS
- Take Home Messages for Practitioners -Coronary Artery Disease
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New Guidelinesfor Myocardial Revascularization
ESC Stockholm29th of August 2010
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EHJ, 31: 2501-2555, (2010)
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Only 1 year laterEHJ-online published August 26, 2011
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Criteria for high risk with indication for
invasive management in patients with NSTE-ACS
European Heart JournalAdvance Access published August 26, 2011
High-sensitivityTroponin
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Rapid rule-out of ACS with high-sensitivity troponin.
European Heart JournalAdvance Access published August 26, 2011
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The new ESC NSTE-ACS Guidelines arehelpful for decision of invasive vs. early ruleout regimen.
Elderly patients with NSTE-ACS often have nobenefit from an invasive approach.
Take Home Messages for Practitioners:Revascularization in NSTE-ACS
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1. Impressions and General Informations
2. Update on Indications for Revascularization
NSTE-ACS
Stable CAD
3. Update on Drug-Eluting Stents
4. Update on Oral Anticoagulation in ACS
5. Update on new Oral Antiplatelet Drugs
- Take Home Messages for Practitioners -Coronary Artery Disease
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EHJ, 31: 2501-2555, (2010)
Bypass Surgery (CABG) versus in Patients with stable CAD
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In patients with stable CAD, complex anatomy with a SYNTAXscore 33, bypass surgery should be strongly considered.
Since the CREDO-Kyoto study was not randomized, patients witha low SYNTAX score have further to be evaluated.
Take Home Messages for Practitioners:Revascularization in stable CAD
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1. Impressions and General Informations
2. Update on Indications for Revascularization
3. Update on Drug-Eluting Stents
4. Update on new Oral Anticoagulation in ACS
5. Update on new new Oral Antiplatelet Drugs in ACS
- Take Home Messages for Practitioners -Coronary Artery Disease
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RAVEL-Study(ESC, Stockholm, September 2001)
Bare Metal Stent Cypher-Stent
Patients n=120 n=118
Results after 12 Months:
Restenosis: 26,0% 0%
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Mortality
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EHJ, 31: 2501-2555, (2010)
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R d d DES
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EHJ, 31: 2501-2555, (2010)
Recommended DES
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Stent ThrombosisEvidence from Clinical Trials
Stephan Windecker
Department of Cardiology
Swiss Cardiovascular Center and Clinical Trials Unit Bern
Bern University Hospital, Switzerland
Definite Stent Thrombosis With DES:
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0 1 2 3 4
Time since PCI in years
0
1
2
3
4
5
Cumulati
veincidence,
%
Months 1 12 24 36 48
Cumulative incidence, % 1.2 1.6 2.1 2.7 3.3
Patients at risk 7538 7210 5164 2790 1051
Incidence density
1.0 / 100 pt years
3.3%
3.5
Definite Stent Thrombosis With DES:Bern - Rotterdam Cohort Study
Daemen J et al. Lancet2007;369:667-78
192 ST casesin a cohortof 8.146 patients
Updated
Follow-up to
4 Years
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Very Late
Stent
Thrombosis
Bavry A et al. Lancet2008
Prevention of Very Late ST New Stent Technology
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BiodegradablePolymer
abluminal only
After releaseof polymer
StentStrut
StentStrut
Polymer
coating
New GenerationDES
EndothelialProgenitor Cell Capture
Biodegradable Polymers Polymer Free Surface Bioabsorbale Stents
Prevention of Very Late ST New Stent TechnologyFirst Generation
DES
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RESET Trial
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RESET Trial(Randomized Evaluation of Sirolimus-eluting versus Everolimus-eluting stent Trial)
Imaging Sub-studies at 8-12 months:
Angiography (500 patients), IVUS/OCT (120 patients), Endothelial function (100 patients)
(Scheduled follow-up angiography by local site protocol was allowed beyond 240 days. )
Primar Endpoints and Sample Si e Calc lation
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Primary Endpoints and Sample Size Calculation
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Death/Myocardial Infarction
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Definite/Probable Stent Thrombosis
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COMPARE: First Definite Stent Thrombosis @ 2 yr
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COMPARE: First Definite Stent Thrombosis @ 2 yr(Definite according to ARC)
2.7 %
0.6 %
Taxus
XienceP < 0.0001 (log-rank test)
RR = 0.21 (0.08-0.55)
0.3 %
2.0 %
1.7 %
2.1 %
Definite or Probable ST Landmark Analysis
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4%
2%
0%
Time after Initial Procedure (days)
C
umulativeIncidence
ofDef/ProbThrom
bosis
Endeavor 732 732 719 716 710 699 688 684 680
Taxus 734 734 721 718 714 701 690 681 674
360 450 540 630 720 810 900 990 1080
0.1%
1.6%
1.5%
1-3 year HR0.09 [0.01, 0.71]
P = 0.004
Endeavor Zotarolimus-eluting
Taxus Paclitaxel-eluting
Definite or Probable ST Landmark Analysis
1-3 Years ENDEAVOR IVLeon M et al. JACC Intv2010;3:104350
Comparison of Everolimus-Eluting and
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15%
0%
Cumul
ativeIncidenceofEven
ts
5%
10%
0 6 12 18 24
1.9%
1.0%
Resolute ZES (N = 1140)
Xience V EES (N = 1152)
Months
P= 0.07
Definite or Probable ST Through 2 Years
p g
Zotarolimus-Eluting Resolute StentSerruys PW et al. N Engl J Med2010
Silber S et al. Lancet2011
P= 0.05
1.6%
0.5%
1.0%0.5%
4.4%4.9%
-1.0%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
ZES EES
Cum
ulativeincidence
ST associated Not ST associated
5.4% 5.4%P = 1.0
P = 0.57
P = 0.23
Cardiac Death or MI
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Conclusion:No significant differences in tissue coverage, malapposition orlumen/stent areas and volumes were detected by OCT between thehydrophilic-polymer coated Resolute Zotarolimus-eluting and the
fluoropolymer-coated Everolimus-eluting stent 13 months follow-up.
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Drug-eluting stents are the default stenting strategy - unlessthere are concerns or contraindications to prolonged dualantiplatelet therapy.
Very late stent thrombosis is somewhat more frequent with firstgeneration DES.
Since with newer generation DES stent thrombosis has becomea minor issue, newer generation DES should be preferred.
Take Home Messages for Practitioners:Drug-Eluting Stents (DES)
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1. Impressions and General Informations
2. Update on Indications for Revascularization
3. Update on Drug-Eluting Stents
4. Update on new Oral Anticoagulation in ACS
5. Update on new Oral Antiplatelet Drugs in ACS
- Take Home Messages for Practitioners -Coronary Artery Disease
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Although oral anticoagulation with new drugs were the highlight
at the ESC 2011 in patients with atrial fibrillation, positive effectshave not been shown in patients with ACS.
In addition to the guideline-oriented dual anti-platelet ACStreatment, the addition of the oral factor Xa inhibitor Darexabanshowed an increased risk of bleeding without a reduction of
ischemic events. We have to wait for the results of the ongoing ATLAS trial.
Take Home Messages for Practitioners:Oral Anticoagulation in ACS
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1. Impressions and General Informations
2. Update on Indications for Revascularization
3. Update on Drug-Eluting Stents
4. Update on new Oral Anticoagulation in ACS
5. Update on new Oral Antiplatelet Drugs in ACS
- Take Home Messages for Practitioners -Coronary Artery Disease
P2Y12 Inhibitors
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STEMI
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EHJ, 31: 2501-2555, (2010)
Same level ofrecommendation
NSTE-ACS
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EHJ, 31: 2501-2555, (2010)
Different levels ofrecommendation
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Ticagrelor
Oral Antiplatelet Agents in NSTE-ACS
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p g
European Heart Journal
Advance Access published August 26, 2011
Oral Antiplatelet Agents in NSTE-ACS
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p g
European Heart Journal
Advance Access published August 26, 2011
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In the new ESC NSTE-ACS guidelines, Prasugrel was upgradedfrom IIa B (in 2010) to I B.
Now, the level of recommendation for Prasugrel and Ticagrelor isthe same for both drugs in NSTE-ACS and STEMI.
Clopidogrel is now recommended only for patients who cannot
receive Prasugrel or Ticagrelor.
Take Home Messages for Practitioners:New Oral Antiplatelet Drugs in ACS
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Munich is a great and lovely city
Munich is waiting for you !
Take Home Messages for Practitioners:- the last one -
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