Antithrombotic therapy after pci in atrial fibrillation 2016

Stent e fibrillazione atriale: singola,

duplice o triplice terapia

antitrombotica?

F Arrigo, Messina

Arrigo, Messina (Italy) 2016

Prevalenza con l’età

Trend futuro


104 cohort studies. 587,867 participants with AF Outcome Relative risk 95% CI

Heart failure 4.99 3.04–8.22

Stroke 2.42 2.17–2.71

CV mortality 2.03 1.79–2.30

Major CV events 1.96 1.53–2.51

Sudden cardiac death 1.88 1.36–2.60

Chronic kidney disease 1.64 1.41–1.91

Ischemic heart disease 1.61 1.38–1.87

Allcause mortality 1.46 1.39–1.53

Peripheral arterial disease 1.31 1.19–1.45

Odutayo A, Wong CX, Hsaio AJ, et al. Atrial fibrillation and risks of cardiovascular disease, renal disease, and death: systematic review and metaanalysis. BMJ 2016; DOI:10.1136/bmj.i4482

Atrial Fibrillation and Nonstroke Outcomes


RiskAdjusted InHospital Mortality After PCI

Multicenter registry Blue Cross Blue Shield of Michigan CV Consortium.

• Data for consecutive 113,283 PCI cases from 47 hospitals between 4/2011 and 12/2014.

• A history of AF was present in 13,912 patients (12%).

• Except in rare cases, patients were not taking oral anticoagulation at the time of PCI

• Patients with a history of AF were more likely to have inhospital complications, including inhospitalmortality (3% vs. 1%).

Sutton NR et al2016;68(9):895904.

Outcomes of Patients With Atrial Fibrillation Undergoing PCI


Multicenter registry Blue Cross Blue Shield of Michigan CV Consortium.

• Data for consecutive 113,283 PCI cases from 47 hospitals between 4/2011 and 12/2014.

• A history of AF was present in 13,912 patients (12%).

• Except in rare cases, patients were not taking oral anticoagulation at the time of PCI

• Patients with a history of AF were more likely to have inhospitalcomplications, including inhospital mortality (3% vs. 1%).

RiskAdjusted InHospital Mortality After PCISutton NR et al2016;68(9):895904.



Sutton NR et al2016;68(9):895-904.


Risk -Adjusted InHospital Mortality After PCI


Propensity-matched inhospital outcomes of patients with and without a history of atrial fibrillation (AF) undergoing PCI.


EuroObservationalResearchProgrammeAtrialFibrillation (EORP-AF) Pilot General Registry

Europace Advance Access published December 17, 2013

3119 patients from February 2012 to March 2013


Stent e fibrillazione atriale

• Il trattamento più efficace per prevenire iltromboembolismo nella fibrillazione atriale è la Terapia Anticoagulante Orale (TAO).

• La terapia più efficace per prevenire la trombosi intrastent dopo PCI è la doppiaantiaggrezione piastrinica (DAPT) con aspirinae P2Y12 inibitori.


Go, A. S. et al. JAMA 2001;285:2370-2375.

OAC vs. DAPT

Stroke Subacute stent thrombosis

The ACTIVE Investigators. Lancet 2006;367:1903-12 Bertrand ME et al. Circulation 1998;98:1597-1603


Fibrillazione AtrialeAngioplastica Con

Stent

Rischiotromboembolie

Trombosiintrastent

TAO DAPT

Rischio emorragico


FARMACI ANTITROMBOTICI (2016)operano con meccanismi differenti e talora complementari

• Antiaggreganti piastrinici – Inibitori COX-2 (Aspirina, Indobufene)– Inibitori P2Y12 (Ticlopidina, Clopidogrel, Prasugrel, Ticagrelor,

Cangrelor)– Inibitori PDE III (Dipiridamolo, Cilostazolo) – Inibitori GP IIb/IIIa (Abcxmab, Tirofiban)

• Anticoagulanti diretti – Agenti antitrombinici (Irudina, Dabigatran); Inibitori Xa

(Fondaparinux, Rivaroxaban, Edoxaban, Apixaban )

• Anticoagulanti indiretti – Eparina (non frazionata, a basso peso molecolare);– Dicumarolici (Warfarin, acenocumarolo, fenprocumone)

• Trombolitici – Attivatori esogeni ed endogeni del plasminogeno


Options for antithrombotic regimens in patients with AF undergoing PCI.

P. Cannon et al. RE-DUAL PCI Trial. Clinical Cardiology 2016

Additional nuances of these strategies could be applied by changing the duration of antiplatelettherapy.


Terapia antitrombotica multipla• Singola terapia antitrombotica

– Aspirina o inibitore P2Y12 o TAO (Warfarin o NOAC)

• Doppia terapia antiaggregante (DAPT)– Aspirina + inibitore P2Y12

• Doppia terapia antitrombotica (DAT) • Aspirina o inibitore P2Y12 + TAO (Warfarin o NOAC)

• Tripla terapia antitrombotica (TT)– Aspirina + inibitore P2Y12 + TAO (Warfarin o NOAC)

• Tripla terapia antiaggregante (TAPT)– Aspirina + inibitore P2Y12 + Antagonista PAR-1 (Voraxapar) o Inibitore PDE III

(Dip o Cilostazolo)

• Doppia terapia antiaggregante parenterale– inibitore P2Y12 (Cangrelor) + Tirofiban


Valutazione del rischio

CHA2DS2-VASc

• Scompenso Cardiaco 1 punto

• Ipertensione a. 1 punto

• Età> 75 anni 2 punti

• Diabete mellito 1 punto

• Pregresso ictus, TIAo TE 2 punti

• Storia di Mal. vasc. (IMA, PAD, placca) 1 punto

• Età 65 -74 anni 1 punto

• Sesso femminile 1 punto

HAS-BLED

• età> 65 anni

• Ipertensione art.

• anormale funzionalità renale ed epatica

• Precedente ictus

• storia di sanguinamento (o predisposizione)

• farmaci che predispongono a sanguinare

• disturbi da uso di alcol

• INR labile


2014


Haemorrhagic risk Stroke risk Clinical setting Recommendations

Low or moderate (HAS-BLED 0–2)

Moderate(CHA2DS2-VASC = 1 in

males)

Stable CAD At least 4 weeks (no longer than 6 months): triple

therapy of OAC +aspirin + clopidogrel a

Up to 12th month: OAC and clopidogrel (or aspirin) b

Lifelong: OACc

High (CHA2DS2-VASC ≥2)

Stable CAD At least 4 weeks (no longer than 6 months): triple

therapy of OAC + aspirin + clopidogrel d

Up to 12th month: OAC and clopidogrel (or aspirin)

Lifelong: OACc

Moderate (CHA2DS2-VASC = 1 in

males)

ACS 6 months: triple therapy of OAC + aspirin +

clopidogrel


Lifelong: OACc


ACS 6 months: triple therapy of OAC + aspirin +

clopidogrel


Lifelong: OACc

.a Combination of OAC + clopidogrel 75 mg/day or DAPT consisting of aspirin 75-mg/day and clopidogrel 75 mg/day may be considered as an alternative.b Dual antiplatelet therapy consisting of aspirin 75 mg/day and clopidogrel 75 mg/day may be considered as an alternative.c Alone or combined with single antiplatelet therapy only in very selected cases (e.g. stenting of the left main, proximal bifurcation, recurrent MIs etc).d Combination of OAC and clopidogrel 75 mg/day may be considered as an alternative.

2014


7. TheACStrialswere underpowered to demonstrate a reduction in stroke risk by usingNOACsincombination with (dual) antiplatelet therapy in non-AF patients.

8. Given the absence of new data from RCTs and the outcome data coming from‘real-world’ registries, it appears questionable to consider the potential risk of MI as a criterion for selecting the most appropriate NOAC agent in a patient with non-valvular AF. The available data do not suggest that there is a need to switch patients on dabigatran to one of the other NOACs in the event of an ACS developing in a patient with AF.

9. Conversely, in an ACS patient who develops new onset AF, and is at high stroke risk,OACshould be started, whether with a VKA or NOAC. Limited data suggest that use of the new P2Y12 inhibitors would increase the risk of major bleeding, and thus, clopidogrel would be the preferred P2Y12 inhibitor.

Haemorrhagic risk Stroke risk Clinical setting Recommendations

High (HAS-BLED ≥3)


males)

Stable CAD 12 months: OAC and clopidogrel 75 mg/dayb

Lifelong: OACc


Stable CAD 4 weeks: triple therapy of OAC + aspirin + clopidogrel d


Lifelong: OACc


males)

ACS 4 weeks: triple therapy of OAC + aspirin + clopidogrel a


Lifelong: OACc


ACS 4 weeks: triple therapy of OAC + aspirin + clopidogrel a


Lifelong: OACc

a Combination of OAC + clopidogrel 75 mg/day or dual antiplatelet therapy consisting of aspirin 75-mg/day and clopidogrel 75 mg/day may be considered as an alternative.

b Dual antiplatelet therapy consisting of aspirin 75 mg/day and clopidogrel 75 mg/day may be considered as an alternative.

c Alone or combined with single antiplatelet therapy only in very selected cases (e.g. stenting of the left main, proximal bifurcation, recurrent MIs etc).

d Combination of OAC and clopidogrel 75 mg/day may be considered as an alternative.

2014


•rischio emorragico alto• TT per 1 mese, poi DAT fino a 1 anno

•rischio emorragico moderato/basso• TT per 6 mesi, poi DAT fino a 1 anno

Sindromi Coronariche Acuteindipendentemente dal rischio trombotico

2014


• rischio emorragico e trombotico alto• TT per 1 mese, poi DAT fino a 1 anno

• rischio emorragico alto e trombotico moderato/basso• DAPT per 12 mesi

• rischio emorragico moderato/basso(indipendentemente dal rischio trombotico)

• TT almeno per 1 mese (non più di 6) poi DAT (1 anno)

CAD stabile

2014


Antithrombotic therapy after an ACS in Afib patients requiring anticoagulation.

2016

2016 ESC Guidelines for the management of atrial Fibrillation. Arrigo, Messina (Italy) 2016

Antithrombotic therapy after elective PCI in Afibpatients requiring anticoagulation.

20162016


Recommendations for combination therapy with oral anticoagulants and antiplatelets

2016


2014 Guidelines from the AHA, ACC, HRS, ACCP

J Am Coll Cardiol 2014; 64: 2246-2280

Class I

• 10. For patients with AF without mechanical heart valves who require interruption of warfarin or new anticoagulants for procedures, decisions about bridging therapy (LMWH or unfractionated heparin) should balance the risks of stroke and bleeding and the duration of time a patient will not be anticoagulated. (Level of Evidence: C)

Class IIb

• 3. In patients with AF undergoing PCI, BMS may be considered to minimize the required duration of dual antiplatelet therapy. Anticoagulation may be interrupted at the time of the procedure to reduce the risk of bleeding at the site of peripheral arterial puncture. (Level of Evidence: C)

• 4. Following coronary revascularization (percutaneous or surgical) in patients with AF and a CHA2DS2-VASc score of 2 or greater, it may be reasonable to use clopidogrel (75 mg once daily) concurrently with oral anticoagulants but without aspirin. (Level of Evidence: B)

2014 Guidelines for the management of patients with atrial fibrillation from the AHA, ACC, HRS, ACCP

Stephen Rechenmacher e James Fang dell’Utah Health Sciences

Center in una ampia review pubblicata sul JACC del 22 settembre, in cui si definiscono tre principi

fondamentali:

•Bridging procedure

Rechenmacher S, Fang J. J Am Coll Cardiol 2015;66:1392–403Arrigo, Messina (Italy) 2016

Bridging procedurereview in cui si definiscono tre principi fondamentali:

• la TAO non deve essere interrotta nelle procedure a basso rischio emorragico

• la bridging therapy non deve mai essere proposta nei pazienti a basso rischio di eventi tromboembolici

• la bridging therapy deve essere limitata ai casi ad alto rischio tromboembolico (TE) e rischio emorragico basso o intermedio

Rechenmacher S, Fang J. J Am Coll Cardiol 2015;66:1392–403Arrigo, Messina (Italy) 2016

Rechenmacher S, Fang J. J Am Coll Cardiol 2015;66:1392–403

• The actual rate of periprocedural TE for unbridged OAC interruptions is rare, estimated at approximately 0.53% from our review of over 23,000 OACinterruptions in 70 studies from 1966 to 2015

CLOTTING AND BLEEDING RISK IN THE PERIPROCEDURAL PERIOD


Rechenmacher S, Fang J. J Am Coll Cardiol 2015;66:1392–403

• Rates of bleeding and TE vary by OAC indication (Figure 1B). For atrial fibrillation, an individual’s daily risk of stroke or transient ischemic attack can be approximated by dividing the annual stroke risk by 365 days.

CLOTTING AND BLEEDING RISK IN THE PERIPROCEDURAL PERIOD

atrialfibrillation


Trials e registri



Isar TRIPLE TT 6 sett vs 6 mesiWOEST non aspirinaSambola A TT vs DT nell’anzianoThe ROCKET AF Trial (NOAC)The ACTION Registry–GWTG TT vs DAPT

ISAR-TRIPLE trial

• endpoint primario – la durata più breve (6 settimane) non è superiore

a 6 mesi di trattamento• 9,8% vs. 8,8% (HR 1.14, 95% CI 0.68-1.91, p = 0,63)

• endpoint secondari– eventi trombotici (morte cardiaca, infarto miocardico, ictus

ischemico, e trombosi dello stent )

• 4.0% vs 4.3%, p = 0.87

– eventi emorragici • 5.3% vs 4.0%, p = 0.44

Duration of Triple Therapy in Patients Requiring Oral Anticoagulation After Drug-Eluting Stent Implantation. The ISAR-TRIPLE Trial

Fiedler, KA et al. J Am Coll Cardiol 2015;65:1619–29


ISAR-TRIPLE trial

Duration of Triple Therapy in Patients Requiring Oral Anticoagulation After Drug-Eluting Stent Implantation. The ISAR-TRIPLE Trial

Fiedler, KA et al. J Am Coll Cardiol 2015;65:1619–29

Cumulative Incidence of the Primary, Secondary Ischemic, and Secondary Bleeding Endpoints

(A) primary endpoint (B) secondary ischemic endpoint

(C) Secondary bleeding endpoint

(A) primary endpoint (cumulative incidence of death, myocardial infarction, stent thrombosis, stroke or TIMI major bleeding)

(B) secondary ischemic endpoint (cardiac death, myocardial infarction, stent thrombosis, or ischemic stroke),

(C) secondary bleeding endpoint (TIMI major bleeding) at 9 months.

HR = hazard ratio.

Months After Randomization



Go, A. S. et al. JAMA 2001;285:2370-2375.

Use of clopidogrel with or without aspirin in patients

taking OAC and undergoing PCI

WOEST Dewilde WJ et al. Lancet 2013;381:1107-15

1° endpoint – Safety (total bleeding)

2° endpoint - Efficacy(stroke, death, MI, re-PCI/CABG, stent thrombosis)

• Double therapy group (n. 279): OAC + 75mg Clopidogrel

• Triple therapy group (n. 284): OAC + 75mg Clopidogrel + 80mg ASA

P=0.0001HR=0.36 95%CI[0.26-0.50]

p=0.025HR=0.60 95%CI[0.38-0.94]



Impact of Triple Therapy in Elderly Patientswith Atrial Fibrillation Undergoing PCI

Sambola A et al. PLOS ONE | DOI:10.1371/journal.pone.0147245 January 25, 2016

Influence of triple therapy (TT) at discharge in patients ≥75 years. Kaplan-Meier survival curves during 1-year follow-up .

Survival free of embolic events Survival free of bleeding events

Survival curves for thromboembolic events diverged very early (before 30 days), but remained quite parallel afterwards, while the curves for bleeding events showed a continuous drop in events over time.


.

Sarafoff N et al. J Am Coll Cardiol 2013;61:2060-6

HR 1.4 (95% CI 0.3-6.1; p= 0.61)HR 4.6 (95% CI 1.9-11.4; p<0.001)

Triple therapy of VKA + aspirin + clopidogrel/prasugrel after PCI

BleedingBleeding MACCE


• Treatment group of the ROCKET AF trial (Rivaroxabancompared with VKA).

• 153 patients (1.1%) underwent PCI during a median 806 days of follow-up.

• Study drug was continued during PCI in 81% of patients.


The ROCKET AF Trial

JACC Cardiovasc Interv. 2016 Aug 22;9(16):1694-702Arrigo, Messina (Italy) 2016

Triple Therapy Among Older Pts With AMI and AF. The ACTION Registry–GWTG

• The ACTION Registry–GWTG is a national quality improvement registry capturing data on consecutive MI patients treated at >500 hospitals in the United States.

• Among 4,959 MI patients presenting with a history of AF who were treated with PCI, 27.6% (n = 1,370) were discharged on triple therapy (warfarin + DAPT), and 72.4% (n = 3,589) were discharged on DAPT (aspirin and a P2Y12antagonist)

Hess, C.N. et al. J Am Coll Cardiol. 2015; 66(6):616–27. Arrigo, Messina (Italy) 2016


Hess, C.N. et al. J Am Coll Cardiol. 2015; 66(6):616–27.

Outcomes According to Triple Therapy Versus DAPT

2-year post-discharge MACE (all-cause mortality , MI readmission, and stroke readmission), and bleeding requiring hospitalization .



Hess, C.N. et al. J Am Coll Cardiol. 2015; 66(6):616–27.

Acute Cerebrovascular Events According to Triple Therapy Versus DAPT


Bleeding in atrial fibrillation patients following myocardial infarction and coronary intervention: a nationwide cohort study

• Subjects with AF hospitalized for Myocardial Infarction (n. 8775 - 76.4%) or PCI (n. 2705 - 23.6%).

• 1521 (17.3%) patients of the group with MI had a PCI performed within 1 week.

• Inclusion criteria were ongoing antithrombotic treatment in subjects alive 7 days after discharge, and no registration with diagnosis of bleeding, MI or ischemic stroke during the quarantine period.

Lamberts M et al. Circulation 2012;126:1185–1193

Nationwide registries in Denmark 2001 - 2009



Crude incidence rates of fatal and nonfatal bleeding according to antithrombotic regimen following inclusion.


• Triple therapy includes ASA, clopidogrel, and VKAs;

• VKA single antiplatelettherapy includes VKA + ASA or clopidogrel;

• DAPT includes ASA and clopidogrel;

• VKA monotherapy includes only VKA;

• Single antiplatelet therapyincludes ASA or clopidogrel.



Thromboembolic and bleeding outcomes following MI or PCI in AF patients according to type of antithrombotic treatment

regimen.


• Triple therapy includes ASA, clopidogrel, and VKAs;

• VKA single antiplatelettherapy includes VKA + ASA or clopidogrel;

• DAPT includes ASA and clopidogrel;

• VKA monotherapy includes only VKA;

• Single antiplatelet therapyincludes ASA or clopidogrel.

DAT

DAT



Rates of primary and secondary end points for patients receiving clopidogrel and OAC and TT at 1 year.

• Am J Cardiol. 2015 May 1;115(9):1185-93.

TT

TT

DAT

DAT


https://www.ncbi.nlm.nih.gov/pubmed/25799015

Rates of primary and secondary end points for patients receiving clopidogrel and aspirin and TT at 1 year.

• Am J Cardiol. 2015 May 1;115(9):1185-93.

TT

TT

DAPT

DAPT



Meta-analysis of RCT and observational results in patients undergoing PCI

triple therapy (TT)(OAC +aspirin+clopidogrel)

dual-antiplatelet therapy (DAPT) (aspirin+clopidogrel)

dual therapy (DAT) (OAC +clopidogrel)

• DAPT vs TT >> reduction of major bleeding and no increased risk of MACE

• DAT vs TT >> reduction of bleeding, without affecting rates of MACE

• Am J Cardiol. 2015 May 1;115(9):1185-93.

DAT vs TT

DAPT vs TT



A proposito di Tripla terapia(OAC +ASA + P2Y12i)

• La doppia terapia (OAC + P2Y12i) è preferibile• riduce significativamente la mortalità per

qualunque causa e i sanguinamenti (WOESTtrial)

• Riduce i sanguinamenti a parità di effetto sugliEventi CV (Metanalisi, ACTION Registry–GWTG)

• la durata della TT per 6 settimane è sufficiente• uguale protezione antitrombotica e tasso di

emorragie nel confronto tra 6 settimane e 6 mesi (ISAR-TRIPLE trial)


La doppia terapia

DAP (OAC + P2Y12i) : il Clopidogrel è preferibile all’aspirina e al

prasugrel in associazione a OAC Sono in corso trials con Ticagrelor e NOAC

DAPT (P2Y12i + aspirina): indicata solo in pazienti a basso rischio

trombotico (CAHDS 0-1)


scenari


Scenario 1a

a NOAC al dosaggio efficace più basso + ASA + Clopidogrelb prasugrel e ticagrelor non dovrebbero essere usati, a meno di provato insuccesso di aspirina +

clopidogrel

Rischio emorragicobasso/intermedio

Rischio emorragico alto

CAD stabile 0 -1 mesi Tripla Terapia a

1-12 mesi DAT (NOAC+ Clo) b

>12 mesi NOAC

0 -1 mesi Tripla Terapia a


> 6 mesi NOAC

SCA 0 -6 mesi Tripla Terapia a


>12 mesi NOAC

0 -1 mesi Tripla Terapia a

1-12 mesi DAT (NOAC+ Clo) c

> 12 mesi NOAC

Pz con FA a rischio trombotico basso/moderato (CHA2DS2-VASc ≤2) non in trattamento anticoagulante

• DAPT con aspirina + ticagrelor (Clopidogrel se rischio emorragico alto) per 6 mesi

• Dopo, valutare l’indicazione a NOACArrigo, Messina (Italy) 2016

Scenario 1b

a NOAC al dosaggio efficace più basso + ASA + Clopidogrelb NOAC + aspirina o clopidogrel



CAD stabile 0 -1 mesi Tripla Terapia a

1 -12 mesi DAT b

> 12 NOAC

0-1 mesi Tripla Terapia a

1 - 6 mesi DAT b

> 6 mesi NOAC

SCA 0 -6 mesi Tripla Terapia a

6 -12 mesi DAT b

>12 NOAC

0 - 1 mesi Tripla terapia a

1 -12 mesi DAT b

> 12 mesi NOAC

Pz con FA a rischio trombotico alto (CHA2DS2-VASc>2) non in trattamento anticoagulante

• TT (NOAC al dosaggio efficace più basso+ASA+Clopidogrel) per 12 mesi

• Se rischio emorragico alto, DAT con NOAC + Clopidogrelper 6 mesi

• Dopo valutare l’indicazione a NOACArrigo, Messina (Italy) 2016

Scenario 2

a TAO + ASA + Clopidogrel. Se NOAC ridurre il dosaggio. b TAO + aspirina o clopidogrelc In pz ad alto rischio coronarico può essere presa in considerazione la DAT con TAO e aspirina

o clopidogrel



SCAD 1-30 gg Tripla Terapia a

1-12 mesi DAT b

>1 anno TAO monoterapia c

1-30 gg Tripla Terapia a

1-6 mesi DAT b

>6 mesi TAO monoterapia c

SCA 0-6 mesi Tripla Terapia a

6-12 mesi DAT b


1-30 gg Tripla Terapia a

1-12 mesi Doppia Terapia b


Pz con FA in trattamento anticoagulante(AVK con INR corretto o NOAC)

• DAT con TAO + Clopidogrel per 1 anno• Se rischio emorragico alto BMS e DAT per 1 mese• Dopo, TAO monoterapia


Scenario 3

Non indicazioni specifiche nelle linee guida

Pz con FA in trattamento anticoagulantecon AVK e INR elevato

• CAD stabile • Posporre la procedura fino a regolarizzazione INR

• SCA• solo Clopidogrel fino a normalizzazione INR, poi

reintrodurre TAO a dosi opportune

EuroObservationalResearchProgrammeAtrialFibrillation (EORP-AF)

Whole

cohort

Paroxysmal Persistent AF Permanent P value

Labile INRs (%) (if on VKA only) =>.without

condition 20.2 28.0 12.5 27.8 0.272



Quali e quanti farmaci usiamo e per quanto tempo?

Una risposta valida per tutti non esiste e la gestione della terapia antitrombotica è complessa e spesso individuale.

Le principali variabili da considerare sono

• Età

• Sindrome clinica

• Rischio tromboembolico

• Rischio emorragico

• Terapia antitrombotica precedente

• Il tipo di stent



La gestione del paziente con fibrillazione atriale e Sindrome Coronarica Acuta (SCA) o intervento coronarico percutaneo (PCI) è una sfida della pratica clinica.

Il punto critico è trovare l’equilibrio ottimale per prevenire gli eventi trombotici, come la trombosi dello stent e lo stroke cardioembolico, senza aumentare il rischio di eventi emorragicimaggiori.

La rapida evoluzione farmacologica e tecnologica rende spesso superati i risultati dei trial clinici di riferimento.


Grazie per l’attenzione

Stent e fibrillazione atriale: singola,

duplice o triplice terapia antitrombotica?

LVIII congresso della sezione

regionale siciliana della Società

Italiana di Cardiologia Roccalumera 17 – 19 novembre 2016


Go, A. S. et al. JAMA 2001;285:2370-2375.

Strategie per evitare il rischio emorragico

1 Ridurre il dosaggio di OAC (target INR 2.0-2.5)

2. Ridurre la durata della Triplice Terapia (1 - 3 mesi)

3.Somministrare di routine farmaci gastroprotettivi

(PPIs)


Health & Medicine

Antithrombotic therapy after pci in atrial fibrillation 2016