I Reunión “Avances en SCA”(día 2)

Ángel Cequier

Vicepresidente Sociedad Española de Cardiología

Director Area de Enfermedades del Corazón

Hospital Universitario de Bellvitge. IDIBELL

Universidad de Barcelona. Hospitalet de Ll. Barcelona

Non ST Non ST -- Elevation Acute Elevation Acute

Coronary SyndromeCoronary Syndrome

Embolization and Embolization and microvascularmicrovascular

occlusion in nonocclusion in non--ST ACSST ACS

Plaque rupture and Plaque rupture and

thrombus in STEMIthrombus in STEMI

ST ST -- Elevation Acute Elevation Acute

Myocardial InfarctionMyocardial Infarction

Hamm CW et al. EHJ 2011 doi:10.1093/ehr236

DecisionDecision--Making Algorithm in ACSMaking Algorithm in ACS

2011 ACC/AHA Focused Update Guidelines for UA/NSTEMI2011 ACC/AHA Focused Update Guidelines for UA/NSTEMI

Anderson et al. Circulation/JACC 2011

Early Invasive Early Invasive vsvs Conservative TherapyConservative Therapy

Relative Risk of Outcomes. Mean F/U 2 yearsRelative Risk of Outcomes. Mean F/U 2 years

AllAll--cause mortalitycause mortality Recurrent nonRecurrent non--fatal MIfatal MI

Influencia del tipo de Hospital en el Tratamiento y Influencia del tipo de Hospital en el Tratamiento y

Pronóstico de los ptes con SCAseSTPronóstico de los ptes con SCAseST

Ruiz-Nodar JM, Cequier A, Lozano T, et al. REC 2010; 63: 390

Estudio GYSCAEstudio GYSCA

Curvas KaplanCurvas Kaplan--Meier de supervivencia libre Meier de supervivencia libre

de MACE (muerte, SCAseST o de MACE (muerte, SCAseST o

revascularización)revascularización)

Pacientes con SCAseST ingresados en Hospitales sin Hemodinámica son tratados Pacientes con SCAseST ingresados en Hospitales sin Hemodinámica son tratados

con menor adherencia a las Guías. Adicionalmente el tipo de Hospital puede tener con menor adherencia a las Guías. Adicionalmente el tipo de Hospital puede tener

una influencia en el pronósticouna influencia en el pronóstico

p<0.01 todas las comparacionesp<0.01 todas las comparaciones

Hospital Terciario Comarcal

AngiographyAngiography: 61 : 61 -- 63 %63 %

PCI: 31PCI: 31-- 34 %34 %

MASCARA MASCARA RegistryRegistry. REC 2008; 61: 803. REC 2008; 61: 803

GYSCA GYSCA RegistryRegistry. REC 2010; 63: 390. REC 2010; 63: 390

SYNERGY. JAMA 2005: 294: 2594SYNERGY. JAMA 2005: 294: 2594

Cequier A. REC 2008; 61: 793Cequier A. REC 2008; 61: 793

Ticagrelor Ticagrelor vs Clopidogrel in Patients with ACSvs Clopidogrel in Patients with ACS

WallentinWallentin et al. NEJM 2009; August 30; on lineet al. NEJM 2009; August 30; on line

PLATO StudyPLATO Study

TicagrelorTicagrelor: : 180 mg loading dose, 90 mg twice daily180 mg loading dose, 90 mg twice daily

Clopidogrel: Clopidogrel: 300300--600 mg loading dose, 75 mg daily600 mg loading dose, 75 mg daily

Composite endComposite end--point: point:

CV death, MI or strokeCV death, MI or stroke Time to the First Major Bleeding endTime to the First Major Bleeding end--pointpoint

11.7%

9.8 %

n= 18624 n= 18624 ptspts, ACS, with or without ST, ACS, with or without ST--segment elevation segment elevation

(28% planned for non(28% planned for non--invasive management)invasive management)

Adverse Impact of Adverse Impact of

Bleeding on Bleeding on

Prognosis in PatientsPrognosis in Patients

with ACSwith ACS

Mortality during the first 30 days

p<.0001p<.0001

12.8 %12.8 %

2.5 %2.5 %

OASIS Registry, OASISOASIS Registry, OASIS--2, 2,

CURE CURE (n= 34146 ptes)(n= 34146 ptes)

Circulation 2006; 114: 774Circulation 2006; 114: 774

ACUITY ACUITY

TrialTrial

JACC 2007; JACC 2007;

49:136249:1362

3 %3 %

8 %8 %

p< .001p< .001

Blood Blood

Transfusion Transfusion

and and

Clinical Clinical

Outcome in Outcome in

ACSACS

Rao et al. JAMA Rao et al. JAMA

2004; 292: 15572004; 292: 1557

Major Bleeding

Non access-site related

60 - 70 %

(ACUITY, TRITON-TIMI 38)

TicagrelorTicagrelor vs Clopidogrel in ACS vs Clopidogrel in ACS PatientsPatients WithWith

NonNon--IInvasivenvasive ManagementManagement PLATO PLATO

TrialTrial

James SK, et al. BMJ 2011; 342: d3527

Benefits of ticagrelor for nonBenefits of ticagrelor for non--invasive management were invasive management were

consistent with the overall PLATO resultsconsistent with the overall PLATO results

Non-Invasive

Invasive

Non-Invasive: HR 0.85 (CI 0.73-1.00); p= 0.04

*Major bleeding: non-CABG-related TIMI major bleeding

1. Antiplatelet Trialists' Collaboration, 1994; 2. Antithrombotic Trialists' Collaboration, 2002;

3. Wiviott et al, 2007; 4. Wallentin et al, 2009

20.0 2.8* 2.2* 0.8 1.3

1.8* 2.4* 0

5

10

15

20

25

None

–25%

15.0

ASA1,2

–20%

12.1

ASA + clopidogrel3

ASA +

–19%

9.9

prasugrel3

11.7

ASA + clopidogrel4

Even

t ra

te (

%)

–16%

ASA +

9.8

ticagrelor4

CV death, MI or stroke

Major bleeding

Prevención Secundaria en el SCA

La incidencia de nuevos eventos CV (muerte, IM o ictus) a 1 año

tras un evento inicial, continúa siendo elevada, ~10%

TRITON TIMI 38 PLATO

Reperfusion Therapy for

Patients with STEMI

2012

Tarantini G, et al. EHJ 2010; 31: 676 / Tarantini G, et al. AHJ 2011; 161: 247.

PPCI for AMI PPCI for AMI

The RiskThe Risk--Time relationshipTime relationship

The need to quantify the impact of delayThe need to quantify the impact of delay

Baseline mortality risk of STEMI is a major determinant of the

acceptable time delay to choose the most acceptable therapy.

IntraaorticIntraaortic BalloonBalloon SupportSupport forfor AMI AMI

withwith CardiogenicCardiogenic ShockShock IABPIABP--SHOCK II SHOCK II

TrialTrial

Thiele H, et al. NEJM 2012; 367: 1287

The use of The use of IAoBIAoB counterpulsationcounterpulsation did not reduce 30did not reduce 30--day mortality in day mortality in

ptesptes with cardiogenic shock complicating AMI treated with PPCIwith cardiogenic shock complicating AMI treated with PPCI

600 patients with cardiogenic shock 600 patients with cardiogenic shock

complicating AMI, randomized to complicating AMI, randomized to IAoBPIAoBP

vsvs NO NO IAoBPIAoBP. .

Primary endPrimary end--point: point:

3030--day allday all--cause mortalitycause mortality

Time-to-Event

Curves for the

Primary End Point

Subgroup Analysis

I Reunión “Avances en SCA”