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ΑΣΘΕΝΗΣ ΜΕ ΟΞΥ ΣΤΕΦΑΝΙΑΙΑΟ ΣΥΝΔΡΟΜΟ
(ΟΣΣ) Ή PCI KAI KOΛΠΙΚΗ ΜΑΡΜΑΡΥΓΗ.
ΠΡΟΛΗΨΗ ΘΡΟΜΒΟΕΜΒΟΛΙΚΟΥ ΚΙΝΔΥΝΟΥ
ΣΤΕΛΙΟΣ ΠΑΡΑΣΚΕΥΑÏΔΗΣ
ΔΙΕΥΘΥΝΤΗΣ ΕΣΥ
Α΄ Καρδιολογική Κλινική ΑΠΘ,
Νοσοκομείο ΑΧΕΠΑ, Θεσσαλονίκη
NO CONFLICT OF INTEREST
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ΟΑC: Oral AntiCoagulant (Vitamin K Antagonists,
NOAC)
NOAC : Novel Oral AnticoAgulant (dabigatran,
rivaroxaban, apixaban, edoxaban)
ACS: Acute Coronary Syndrome
CAD: Coronary Artery Disease
PCI : Percutaneous Coronary Intervention
Dual therapy: OAC or NOAC + 1 Antiplatelet
Triple therapy: OAC or NOAC + 2 Antiplatelet
DAPT: Dual Antiplatelet Therapy
CHA2DS2-VASc
score 2
score (ESC 2010-2012)
score 1
ΑΙΜΟΡΡΑΓΙΚΟΣ ΚΙΝΔΥΝΟΣ
> 3 : high risk
ESC
2010
ESC
2012
NOACs- Mηχανισμός δράσης
rivaroxaban, apixaban,
edoxaban
dabigatran
NOACs-ΦΑΡΜΑΚΟΚΙΝΗΤΙΚΗ
80%
27%
35%
50%
AF and ACS-PCI
Lip GYH et al. Eur Heart J, August 2014
Antithrombotic management in AF and ACS/PCI
CHA2DS2-VASC=1
Low to intermediate
(HAS-BLED=0-2)
High
(HAS-BLED >3 )
CHA2DS2-VASC > 2
Low to intermediate
(HAS-BLED=0-2)
High
(HAS-BLED >3 )
Antithrombotic therapy in ACS/ PCI and AF
consensus recommendations
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Triple therapy period : as short as possible followed by
Dual therapy OAC plus a single antiplatelet therapy
(preferably clopidogrel 75 mg/day, or aspirin 75–100
mg/day)
The duration of triple therapy is dependent :
acute vs elective procedures
bleeding risk (as assessed by the HAS-BLED score)
type of stent (with a preference for new generation DES
or BMS).
OAC: well-controlled adjusted dose VKA (with TTR
70%) or NOAC.
TTR
(Time in the Therapeutic Range of INR)
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target of TTR > 70 %
(ESC anticoagulation working group position
document)
SAME-TT2R2 score
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Sex (female), Age ( < 60 years),
Medical history (at least two of the following:
hypertension, diabetes, coronary artery disease,
peripheral arterial disease, congestive heart failure,
previous stroke, pulmonary disease, hepatic or renal
disease)
Treatment (interacting drugs, e.g. amiodarone
for rhythm control). All one point
Tobacco use and Race (non-Caucasian). Two points
score 0–1: VKA (warfarin)
score ≥ 2 : NOAC
De Caterina R et al. Thromb Haemost 2013;110:1087–1107
ΝΟACs-ACS
dabigatran, rivaroxaban, apixaban, edoxaban
dual therapy > 1 year
Stable Coronary Artery Disease
NSTEMI-Unstable Angina
NSTEMI-Unstable Angina
NSTEMI-Unstable Angina
OAC –NOAC and PCI. «γέφυρα» με ηπαρίνηενοξαπαρίνη
συνοδεύεται με αυξημένο αιμορραγικό
κίνδυνο πιθανώς λόγω διπλής
αντιπηκτικής δράσης στην μεταβατική
περίοδο
NSTEMI-Unstable Angina-STEMI
STEMI AND AF
 Primary PCI (radial access, Class I, level of
evidence A), aspirin, clopidogrel, and heparin
(UFH) or bivalirudin
 Temporarily stop OAC, NOAC therapy
 No ‘routine’ use of GP IIb/IIIa inhibitors or
ticagrelor or prasugrel (Class IIb, level of
evidence B)
 Ιn HAS-BLED score: 0–2 triple therapy
(OAC, aspirin, and clopidogrel) should be
considered for 6 months following PCI
irrespective of stent type
STEMI IN AF under NOACs
WOEST study
(What is the Optimal antiplatElet and anticoagulant therapy in pts with
oral anticoagulation and coronary StenTing)
n=573 , F/U: 1 year
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Dual therapy (VKA plus clopidogrel) or
Triple therapy (VKA plus aspirin and clopidogrel) after
coronary stenting
Dual therapy: 50% less total bleeding complications
(without significant differences in major bleeds), with no
detectable increase in the rate of thrombotic events, especially
stent thrombosis.
significant reduction in mortality at 12 months with dual
therapy.
Dewilde WJ , et al. Lancet 2013;381:1107-15
Ongoing randomized controlled trials (OAC-VKA)
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ISAR-TRIPLE (Triple Therapy in Patients on Oral
Anticoagulation After Drug Eluting Stent Implantation
(clopidogrel 75 mg for 6 weeks, aspirin and OAC)
following implantation of a DES : composite end-point of
death, MI, definite stent thrombosis, stroke, or major bleeding
at 9 months.
MUSICA-2 (Anticoagulation in Stent Intervention),
Triple therapy of acenocoumarol, low-dose (100 mg) aspirin
and clopidogrel vs. high-dose (300 mg ) aspirin and
clopidogrel in patients with AF and low-to-moderate risk of
stroke (CHADS2 ≤ 2) referred for PCI.
 LASER (Real Life Antithrombotic Stent Evaluation Registry)
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Ongoing trials-NOAC in PCI and AF
PIONEER AF-PCI trial
rivaroxaban (2.5 mg b.i.d. followed by 15 mg q.d. or
10 mg q.d. in subjects with moderate renal impairment)
in comparison with a dose-adjusted VKA treatment
strategy in AF and PCI.
All pts will receive either single or dual antiplatelet
therapy. This trial will also study the prasugrel and
ticagrelor in combination with OAC.
RE-DUAL PCI
dabigatran (110 or 150 mg) + single antiplatelet vs
- Warfarin + dual antiplatelet
n=30866
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In pts with a recent ACS the
addition of a NOAC to
antiplatelet therapy
results in a modest (30%)
reduction in cardiovascular
events but a substantial
increase in bleeding, most
pronounced (double) when
NOACs are combined with
dual antiplatelet therapy
Oldgren J, et al. EHJ 2013;341:1670-80
DABIGATRAN antidote
Idarucizumab is a fully humanized antibody
fragment, or Fab, being investigated as a specific
antidote for dabigatran with no other expected
interactions
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A global phase III study, RE-VERSE AD is underway in
patients taking PRADAXA who have uncontrolled
bleeding or require emergency surgery or procedures
(NCT02104947)
RIVAROXABAN, APIXABAN, EDOXABAN
Andidotes
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Andexanet alfa: F Xa Inhibitor Antidote
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First-in-class recombinant, modified Factor Xa molecule that is being
developed as a direct reversal agent (antidote) for patients receiving
a Factor Xa inhibitor who suffer a major bleeding episode or who
may require emergency surgery
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Phase 3 studies
ANNEXA- A (Andexanet Alfa a Novel Antidote to the
Anticoagulant Effects of F Xa Inhibitors – Apixaban)
ANNEXA- R (Andexanet Alfa a Novel Antidote to the
Anticoagulant Effects of F Xa Inhibitors – Rivaroxaban), in
healthy volunteers are ongoing.
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ANNEXA- E (Andexanet Alfa a Novel Antidote to the
Anticoagulant Effects of F Xa Inhibitors – Edoxaban), is planned.
Συμπέρασματα
H χορήγηση αντιθρομβωτικής αγωγής σε οξύ
στεφανιαίο σύνδρομο ή PTCA με ΚΜ είναι
συνάρτηση
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θρομβοεμβολικού κινδύνου CHA2DS2-VASc score
αιμορραγικού κινδύνου HAS-BLED score
επείγουσας ή μη παρέμβασης
Συμπέρασμα
 Η διάρκεια της τριπλής θεραπείας (αντιπηκτικά
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ΟΑC-NOAC και διπλή αντιαιμοπεταλιακή) η
συντομότερη, ακολοθούμενη απο διπλή αγωγή
(αντιπηκτικά ΟΑC-NOAC και κλοπιδογρέλη 75 mg
ή ασπιρίνη 75-100 mg)
> έτος: μόνο αντιπηκτικά ΟΑC-NOAC
Αναστολείς γλυκοπρωτεϊνικών υποδοχέων, GP
IIb/IIIa, ticagrelor ή prasugrel : να μη
χρησιμοποιούνται μέχρι την εξαγωγή
συμπερασμάτων απο μεγάλες μελέτες
ΕΥΧΑΡΙΣΤΩ ΓΙΑ ΤΗΝ
ΠΡΟΣΟΧΗ ΣΑΣ

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