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5 years after PLATO –
Experience from the Daily
Clinical Practice
Dual Antiplatelet Therapy:
Time for a Paradigm Shift?
Hans Rickli
Goals with antithrombotic treatment
Acute coronary syndrome
Risk reduction of cardiovascular events
Myocardial infarction
Death
Stroke
Risk reduction of stent thrombosis
Prehospital treatment to achieve rapid and
effective platelet inhibition and anticoagulation
Minimizing the risk of bleeding18.06.2015
Complications and outcome in STEMI patients (N=27’207)
*developing during hospitalization
Reduction of time delays Better risk stratification Invasive approach Antithrombotic therapy ……
Reperfusion therapy in STEMI patients (N=27’207)
P<0.001
P2Y12 inhibitors at discharge in ACS patients (N=12,278)
Clopidogrel across spectrum of CAD
Biotransformation Mode of ActionClopidogrel,
Prasugrel und Ticagrelor
Schomig AS. Ticagrelor — Is There Need for a New Player in the Antiplatelet-Therapy Field? New Eng J Med 2009; 361(11): 1108-1111
Antiplatelet therapy: efficacy vs. safety
or Ticagrelor
Cuisset; Euro PCR 2010, Paris
5 years after PLATO: Antiplatelet therapy in
NSTEMI Guidelines
ESC Guidelines for the management of acutecoronary syndromes in patients presenting without
persistent ST-segment elevation; Europ Heart J 2011
18.06.2015
Antiplatelet therapy in patients with STEMI(STEMI 2012)
5 years after PLATO: ESC guidelines 2014
myocardial revascularization
NSTE-ACS undergoing PCI
STEMI undergoing PCI
Windecker et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014 Oct 1;35(37):2541-619
For
med
ical
use
on
ly–
may
con
tain
off
lab
leto
pic
s
Guidelines are usefull but don’t stop
thinking
Prasugrel Ticagrelor
Study design PCI study “All-Comers”-study
invasive invasive or conservative
conservative 0 % 28 %
Revascularization strategy: PCI PCI or CABG
CABG: 1 %10 % of the study group
and 14% of the invasive gr.
PCI: 99 % 62 %
STEMI: 26 % 38 %
Loading with Clopidogrel:Relatively late
300 mg
early
300- 600 mg
Important points to consider:
Triton-TIMI 38: New Engl J Med 2007;357:2001-2015
Plato: N Engl J Med 2009;361:1045-57
0,5 1,0 1,5
Risk increase as compared
Clopidogrel
Risk reduction as compared
to Clopidogrel
Primary endpoint:
Ticagrelor
Triton-TIMI 38: New Engl J Med 2007;357:2001
Plato: N Engl J Med 2009;361:1045-57
0,5 1,0 1,5
Risk increase as compared
Clopidogrel
Risk reduction as compared
to Clopidogrel
Conservative management:
Total mortality
Prasugrel Clopidogrel
--- ---
Ticagrelor Clopidogrel
6,1 %
(signifikant)
8,2 %in PLATO:
n = 5216 = 28%
in TRITON
no conservative group!
Trilogy ACS
Without benefit as
compared to
Clopidogrel
0,5 1,0 1,5
Risk increase as compared
Clopidogrel
Major bleedings: („TIMI major“)
without CABG-Patients
Prasugrel Clopidogrel
2,4 %
(significant)
1,8 %
Ticagrelor Clopidogrel
2,8 %
(significant)
2,2 %
Risk reduction as compared
to Clopidogrel
PLATO Trial PLATO CABG substudy
Wallentin L et al. NEJM 2009;361:1045-57.
11.7%
9.8%
11.6%11.2%
9.7%
4.7%
Held C et al. JACC 2011;57:672-84.
Primary endpoint (MACCE)
Major bleeding
Overall mortality
Major bleeding
trial stopped early when a
planned interim analysis
showed that
pretreatment was
associated with an
increased risk of major
bleeding
7d: (2.6% vs. 1.4%,
p=0.006)
30 days (2.9% vs. 1.5%,
p=0.002)
Clopidogrel vs Prasugrel/Ticagrelor –
Key messages
Prasugrel and Ticagrelor: net clinical benefit over
Clopidogrel in ACS patients
Ticagrelor evaluated in allcomers study (PLATO)
Benefit through all subgroups
CABG/Conservative tx
No restriction in elderly (>75yrs), weight < 60kg and history of
TIA/Stroke
Prasugrel in PCI study (TRITON)
Good results in STEMI pts, diabetic population
No benefit in patients with conservative management (Trilogy ACS)
Elevated bleeding risk with pretreatment (Accoast)
not recommended, if history of Stroke - dose reduction if age > 75
yrs, weight < 60kg)
Major adverse CV events up to 30 days
Definite stent thrombosis up to 10 days
Definite stent thrombosis up to 30 days
Conclusion
Pre-hospital ticagrelor administration a short time before PCI in patients with ongoing STEMI is safe but does not improve pre-PCI coronary reperfusion. It may, however, reduce the risk of post-PCI stent thrombosis.
Windecker et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association of PercutaneousCardiovascular Interventions (EAPCI). Eur Heart J. 2014 Oct 1;35(37):2541-619
5000 Heparin i.v.
Ticagrelor (Brillique®) Loading Dose 2x90 mg/d
Triage im Spital/PCI-Zentrum
Keep it simple in network treatment
RivaroxabanApixabanEdoxaben
Dabigatran
5 years after PLATO: What else…?
Cangrelor
Different Clinical conditions
ACS
– NSTEMI conservative
– NSTEMI/STEMI with
PCI/CABG
Stable CAD with Stents
RCTs with Ticagrelor or
Prasugrel lacking
Important co-factors to consider
• Triple therapy for newer drugs not
approved
• Impact of Age, Diabetes, other
comorbidity….
5 years after PLATO: What else…?
Trends in triple antithrombotic therapy at discharge in ACS patients with atrial fibrillation at admission (n=294)
Increasing rate of Combination of
newer P2Y12 inhibitors together with
OAC
- In hospital bleeding, in hospital-
outcome, at 1 yr?
Increasing rate of triple tx with NOACs
Unpublished data
5 years after PLATO: What else…?
5 years after PLATO – Experience from the
Daily Clinical Practice
• Risk reduction of cardiovascular events remains still a
goal (balance between thrombotic and bleeding risk)
– newer antithrombotics are integrated in daily practice in ACS
– Management of ACS patients in regional networks: need of
simple and clear strategy
– In contrast to the guidelines – a substantial number of ACS patients
is treated with Prasugrel or Ticagrelor in combination with
anticoagulation (VKA or NOACs)
18.06.2015
Thank you!
L.C
H.H
C.1
1.2
011.0
079-E
N
18.06.2015
Fallbeispiel 1a
• 71-jährige Patientin
• Bekannte Koronare und hypertensive Herzkrankheit
• St. n. inferiorem Myokardinfarkt vor Jahren (Stent)
• Beschwerdefrei (keine Angina) und ordentlich belastbar
• Medikation: Bisoprolol (Concor®)
Ramipril (Triatec®)
Atorvastatin (Sortis®)
Aspirin
• Colon-Carcinom: Hemikolektomie links
Gerstein NS, et al. Anesth Analg 2015; 120: 5670-5
Kardiovaskuläres Manual KSSG 2015
Gurbel PA et al. Randomized double-blind assessment of the ONSET and OFFSET of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable
coronary artery disease: the ONSET/OFFSET study. Circulation. 2009;120:2577–2585
* P<0.05, ** P<0.001, *** P<0.0001
Ticagrelor vs. Clopidogrel
ONSET/OFFSET – Studie
Ticagrelor 180-mg Initialdosis in stabilen KHK-Patienten
Clopidogrel 600-mg Initialdosis in stabilen KHK-Patienten