Curiosare fra le raccomandazioni delle Linee Guida ESC ... · PDF fileLinee Guida ESC 2014...

Curiosare fra le raccomandazioni delle

Linee Guida ESC 2014

sulla rivascolarizzazione miocardica

Marco Comeglio

UO Diagnostica e Interventistica Cardiovascolare

Asl 3 Pistoia

Curiosare fra le raccomandazioni delleCuriosare fra le raccomandazioni delle

Linee Guida ESC 2014Linee Guida ESC 2014

sulla rivascolarizzazione miocardicasulla rivascolarizzazione miocardica

Marco ComeglioMarco Comeglio

UO Diagnostica e Interventistica CardiovascolareUO Diagnostica e Interventistica Cardiovascolare

Asl 3 PistoiaAsl 3 Pistoia

L’uomo ha un’insaziabile

curiosità di conoscere ogni

cosa, eccetto quelle che

meritano di essere

conosciuteOscar Wilde

LL’’uomo ha unuomo ha un’’insaziabile insaziabile

curiositcuriositàà di conoscere ogni di conoscere ogni

cosa, eccetto quelle che cosa, eccetto quelle che

meritano di essere meritano di essere

conosciuteconosciuteOscar WildeOscar Wilde

2014 ESC/EACTS Guidelines on Myocardial Revascularisation2014 ESC/EACTS Guidelines on Myocardial Revascularisation

Guidelines and recommendations Guidelines and recommendations should should helphelp healthhealth

professionalsprofessionals to make decisions in their daily to make decisions in their daily

practice; however, the practice; however, the final decisions final decisions concerning an concerning an

individual patient individual patient must be made by the must be made by the responsible responsible

health professionalhealth professional(s), in consultation with the (s), in consultation with the

patientpatient……

PreamblePreamble

1.1. Scores and risk stratification Scores and risk stratification

2.2. Process for decisionProcess for decision--making and patient informationmaking and patient information

3.3. Strategies for diagnosis: functional testing and imagingStrategies for diagnosis: functional testing and imaging

4.4. Revascularization for stable coronary artery diseaseRevascularization for stable coronary artery disease

5.5. Revascularization in nonRevascularization in non--STST--segment elevation acute coronary segment elevation acute coronary syndromessyndromes

6.6. Revascularization in STRevascularization in ST--segment elevation myocardial infarctionsegment elevation myocardial infarction

7.7. Revascularization in patients with heart failure and cardiogenicRevascularization in patients with heart failure and cardiogenic shockshock

8.8. Revascularization in patients with diabetesRevascularization in patients with diabetes

9.9. Revascularization in patients with chronic kidney diseaseRevascularization in patients with chronic kidney disease

10.10. Revascularization in patients requiring valve interventionsRevascularization in patients requiring valve interventions

11.11. Associated carotid/peripheral artery diseaseAssociated carotid/peripheral artery disease

12.12. Repeat revascularization and hybrid proceduresRepeat revascularization and hybrid procedures

13.13. ArrhythmiasArrhythmias

14.14. Procedural aspects of coronary artery bypass graftingProcedural aspects of coronary artery bypass grafting

15.15. Procedural aspects of percutaneous coronary interventionProcedural aspects of percutaneous coronary intervention

16.16. Antithrombotic treatmentsAntithrombotic treatments

17.17. Points of interest and special conditionsPoints of interest and special conditions



ESC STEMI GUIDELINES 2012ESC STEMI GUIDELINES 2012

STREAM StudyNEJM 2013

ICH (1.0% vs. 0.2%, p=0.04)


- 65% CD/NFMI/R.ANGINA

•• DES or BMS ?DES or BMS ?

•• Radial or Femoral ?Radial or Femoral ?

•• Thrombectomy or not ?Thrombectomy or not ?

If there is no contraindications to If there is no contraindications to

prologed DAPT, DES should be prefprologed DAPT, DES should be pref

If performed by an expert radial op, If performed by an expert radial op,

radial access should be preferredradial access should be preferred

Routine thrombus aspiration Routine thrombus aspiration

should be consideredshould be considered

Routine use of distal protection Routine use of distal protection

devices is not recommendeddevices is not recommended

IIa

IIa

IIa

III

B

A

B

C


2014 ESC/EACTS Guidelines 2014 ESC/EACTS Guidelines

on Myocardial Revascularisationon Myocardial Revascularisation

The choice, initiation, combination, and duration of antithromboThe choice, initiation, combination, and duration of antithrombotic tic

strategies for myocardial revascularization depend onstrategies for myocardial revascularization depend on

a.a. The clinical settingThe clinical setting

•• STEMISTEMI

•• NSTENSTE--ACSACS

•• SCADSCAD

b.b. The urgency and mode of the interventionThe urgency and mode of the intervention

•• PCI vs. CABGPCI vs. CABG

Ischaemic and bleeding risks should be evaluated on an individuaIschaemic and bleeding risks should be evaluated on an individual basisl basis

To maximize the effectiveness an reduce the hazard of bleedingTo maximize the effectiveness an reduce the hazard of bleeding



ASA ASA (150(150--300 plus 75300 plus 75--100mg daily) 100mg daily) longlong--term term

regardless of treatment strategyregardless of treatment strategyI A

P2YP2Y1212 inhibitor in addition to inhibitor in addition to

ASA and maintained 12 months ASA and maintained 12 months

PrasugrelPrasugrel (60 mg plus 10 daily)(60 mg plus 10 daily)

TicagrelorTicagrelor (180 mg, Plus 90 x 2 daily) (180 mg, Plus 90 x 2 daily)

I

I

I

A

B

BClopidogrelClopidogrel (600 mg plus 75 daily)(600 mg plus 75 daily)

Only when P or T not possibleOnly when P or T not possible

I BP2YP2Y1212 at the time of FMCat the time of FMC

IIa CGP IIb/IIIa inhibitors for bailGP IIb/IIIa inhibitors for bail--

out or noout or no--reflow reflow

IIb BUpstream GP IIb/IIIa in high Upstream GP IIb/IIIa in high

risk trasferrisk trasfer--PPCIPPCI

STEMISTEMI


AnticoagulationAnticoagulation in addition in addition

to antiPLT for all during PPCI to antiPLT for all during PPCI I A

Isc/Ble risk & SafIsc/Ble risk & Saf--Eff profile Eff profile

drive the choice of the AC drive the choice of the AC I C

UFHUFH (70(70--100 U/Kg) iv Bolus100 U/Kg) iv Bolus

(50(50--70 U/Kg if GPIIb/IIIa)70 U/Kg if GPIIb/IIIa) I C

IIa ABIVALIRUDINBIVALIRUDIN : : 0.75 mg/Kg iv bol + 0.75 mg/Kg iv bol +

1.75 mg/Kg/h up to 4 hours after PCI1.75 mg/Kg/h up to 4 hours after PCI

IIa BENOXAPARINENOXAPARIN iv 0.5 mg/Kg iv 0.5 mg/Kg

with or without GPIIb/IIIawith or without GPIIb/IIIa

Changes respect toChanges respect to


BIVALIRUDIN is recomm BIVALIRUDIN is recomm

over UFH and a GPIIb/IIIaover UFH and a GPIIb/IIIa I B

UFHUFH must be used in pts must be used in pts

not receiving BIVA or not receiving BIVA or

ENOXAENOXA

I C

STEMISTEMI


ASA ASA (150(150--300 plus 75300 plus 75--100mg daily) 100mg daily) longlong--term term

regardless of treatment strategyregardless of treatment strategyI A

P2YP2Y1212 inhibitor in addition to inhibitor in addition to

ASA and maintained over 12 mo.ASA and maintained over 12 mo.

PrasugrelPrasugrel (60 mg plus 10 daily) (60 mg plus 10 daily) coronary coronary

anatomy known and proceding to PCIanatomy known and proceding to PCI

I

I

I

A

B

B

ClopidogrelClopidogrel (600 mg plus 75 daily)(600 mg plus 75 daily)

Only when P or T not possibleOnly when P or T not possibleI B

Ticagrelor Ticagrelor (180 mg, plus 90 x 2(180 mg, plus 90 x 2); mod); mod--toto--high high

ischaemic risk, regardless of initial treatment ischaemic risk, regardless of initial treatment

(including Clopidogrel treatment)(including Clopidogrel treatment)

IIa CGP IIb/IIIa inhibitors for bailGP IIb/IIIa inhibitors for bail--

out or thrombotic complicat. out or thrombotic complicat.

ACSACS

III B

�� PrePre--treatment with PRASUGREL treatment with PRASUGREL

before coronary angiography before coronary angiography

(ACCOAST)(ACCOAST)

�� PrePre--treatment with GP IIb/IIIa treatment with GP IIb/IIIa

Antagonists before coronary Antagonists before coronary

angiographyangiography


AnticoagulationAnticoagulation in addition in addition

to antiPLT for all during PCI to antiPLT for all during PCI I A

Isc/Ble risk & SafIsc/Ble risk & Saf--Eff profile Eff profile

drive the choice of the AC drive the choice of the AC I C

UFHUFH for PCI if patients cannot for PCI if patients cannot

receive BIVALIRUDINreceive BIVALIRUDIN I C

I ABIVALIRUDINBIVALIRUDIN : : As alternative to As alternative to

UFH plus GPI during PCIUFH plus GPI during PCI

IIa BENOXAPARINENOXAPARIN for PCI in pts for PCI in pts

prepre--treated with sc enoxtreated with sc enox

ACSACS

FONDAPARINUX: FONDAPARINUX: single bolus single bolus

of UFH needed during PCIof UFH needed during PCI I C

III B

��Crossover of UFH and Crossover of UFH and

LMWH is not LMWH is not

recommendedrecommended


ASA ASA 150150--300 mg LD if not 300 mg LD if not

--treatedtreatedI C

ClopidogrelClopidogrel 600 mg in elective PCI, 600 mg in elective PCI,

known anatomy, 2 hrs or more beforeknown anatomy, 2 hrs or more before I A

SCADSCAD

Life--long single antiplatelet long single antiplatelet

Rx (usually ASA)Rx (usually ASA) I A

DAPT for at least 1 month DAPT for at least 1 month

after BMSafter BMSI A

DAPT for 6 months after DESDAPT for 6 months after DES I B

UFHUFH 7070--100 U/Kg100 U/Kg I

IBIVALIRUDINBIVALIRUDIN : in case of HIT: in case of HIT

IIaENOXAPARINENOXAPARIN for PCI in pts for PCI in pts

prepre--treated with sc enoxatreated with sc enoxa

BIVALIRUDIN: BIVALIRUDIN: in case of highin case of high--

bleeding riskbleeding risk IIa

EXCELLENTEXCELLENTIt is recommended that DAPT be administered

��SCADSCAD� for at least 1 month after BMS

� for 6 months after new-generation DES

��ACSACS� up to 1 year irrespective of

revascularization strategy (CURE; TRITON; PLATO)

2014 ESC/EACTS2014 ESC/EACTS

Guidelines on Myocardial RevascularisationGuidelines on Myocardial RevascularisationDAPTDAPT--STUDY NEJM 2014STUDY NEJM 2014

0

1

2

3

4

5

0 1 2 3 4 5 6 7 8 9

12 months of clopidogrel12 months of clopidogrel

6 months of clopidogrel6 months of clopidogrel

Months after randomization

Composite of DEATH, MI, ST,Composite of DEATH, MI, ST,

STROKE or TIMI MSTROKE or TIMI M--B (%)B (%)

1.6%1.6%

1.5%1.5%

Δ -0.1%, 1-sided 95% CI 0.5%

P Noninferiority <0.001

ISARISAR--SAFESAFE

RA Harrington, AHA Nov 2014

««Things are clearer Things are clearer –– but not totally clearbut not totally clear»»

Dual NOAC and Clopi: may be

considered in selected patients

(WOEST)

Use of Ticagrelor or Prasugrel as

part of initial triple therapy is not

recommended

Additional iv AC during PCI is

recommended regardless of the

timing of last dose of NOAC

IIb

III

I

IIaPeriprocedural iv AC should be

stopped immediately after PPCI

HAS BLED≥3: NOAC + ASA + Clop

for 1 mo, then NOAC + ASA or

Clop in all settings:

SCAD/ACS/DES

IIaC

C

C

C

B

TRIPLE THERAPY: recommended

in case of firm indication for OAC

AF (CDV≥2); VTE; LV tr; Valve Pr I

C

SCAD + AF: NOAC + ASA + CLOP

for 1 mo w BMS or NG-DES, then

NOAC + ASA or CLOPI up to 12 mo IIa

C

IIaACS + AF: NOAC + ASA + CLOP for

6 mo BMS or DES, then NOAC +

ASA or CLOPI up to 12 mo C

SCAD + AF with a CHA2DS2VASc ≤ 1

DAPT should be consideredIIa

C

NG-DES are preferred over BMS if

bleeding risk is low (HAS-BLED ≤2) IIaC


Preferred are:

�Bivalirudin for Dabigatran

�Enoxaparin for anti-Xa

inhibitors (rivaroxaban or apixaban) to avoid cross-over


PCI or CABG, may be indicated to reduce myocardial ischaemia andPCI or CABG, may be indicated to reduce myocardial ischaemia and its its

adverse clinical adverse clinical manifestationsmanifestations

AnginaAngina: : associated with associated with impaired quality of life, reduced physical endurance, mental impaired quality of life, reduced physical endurance, mental

depression, and recurrent hospitalizations and outpatient visitsdepression, and recurrent hospitalizations and outpatient visits

�� Revascularization by PCI or CABG more effectively relieves anginRevascularization by PCI or CABG more effectively relieves angina, reduces the use a, reduces the use

of antiof anti--angina drugs, and improves exercise capacity and quality of lifeangina drugs, and improves exercise capacity and quality of life, compared , compared

with a strategy of OMT alonewith a strategy of OMT alone

IschaemiaIschaemia is of prognostic importance in patients with SCAD, particularly is of prognostic importance in patients with SCAD, particularly when when

occurring at low work loadoccurring at low work load

�� Revascularization relieves myocardial ischaemia more effectivelyRevascularization relieves myocardial ischaemia more effectively than OMT alonethan OMT alone

The extent, location, and severity of CAD are important prognostThe extent, location, and severity of CAD are important prognostic factors in addition to ic factors in addition to

ischaemia and left ventricular functionischaemia and left ventricular function

Trials of Optimal Medical Therapy

with or without Revascularization




• Underpowered (many exclusion from initial

cohort)

• Investigator selection Bias (post-angio study)

• Low risk pts (0.4% annual cardiac death)

• End Point : all cause death - only 26.7%

confirmed Cardiac Death

• ITT … but huge cross-over

• …..etc…






FAME 2: FFRFAME 2: FFR--Guided PCI versus OMT in SCADGuided PCI versus OMT in SCADNEJM 2012; 367:991

De

ath

, M

I, U

rg R

ev

with documented ischaemia or FFR < 0.80 for stenosis < 90%

Indications for Revascularization in Patients with

Stable Angina or Silent Ischaemia

Indications for Revascularization in Patients with

Stable Angina or Silent Ischaemia


Hybrid procedures, consecutive

or combined, in specific patients IIb

C


Heart team

Male, 55 yrsMale, 55 yrs

HPTN, DIABETESHPTN, DIABETES

ACS: ACS: TnI 1,5 ng/mlTnI 1,5 ng/ml

Cr 1.32 mg/dlCr 1.32 mg/dl

HbA1cHbA1c 7.10 %7.10 %

3V DIFFUSE DISEASE3V DIFFUSE DISEASE

SYNTAX SCORE: 30SYNTAX SCORE: 30

STS : STS : 0.632% mortality0.632% mortality

11.46% morb. mort.11.46% morb. mort.

0.93% perm. stroke0.93% perm. stroke

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