Doppia antiaggregazionedopo impianto di DES:

prolungata... ma non prolungata... ma non troppo?troppo?

Doppia antiaggregazionedopo impianto di DES:

prolungata... ma non prolungata... ma non troppo?troppo?

UO Cardiologia

ASL 9 Grosseto

UO Cardiologia

ASL 9 GrossetoUgo LimbrunoUgo Limbruno

Conflict of Interest: cConflict of Interest: consulting for ABBOTT, CORDIS, BOSTON SCIENTIFIC, TERUMO, BIOTRONIK, PFIZER, ANGELINI, ASTRA ZENECA, TMC, IROKO. Conflict of Interest: cConflict of Interest: consulting for ABBOTT, CORDIS, BOSTON SCIENTIFIC, TERUMO, BIOTRONIK, PFIZER, ANGELINI, ASTRA ZENECA, TMC, IROKO.

risk

ST without DAPT

bleeds with DAPT

time after DES

1 mo 3 mo 6 mo 1 year

DAPT durationDAPT duration

• NEJM 2010;362:1374

• Heart 2009;95:1579

DAPT durationDAPT duration

current practice

??

??

DAPT durationDAPT duration

528 pts

IntentionalIntentionalDAPT withdrawal

IntentionalIntentionalDAPT withdrawal

UnplannedUnplannedDAPT withdrawal

UnplannedUnplannedDAPT withdrawal

≠≠

0.3%/year

0.3%/year

IntentionalIntentionalDAPT withdrawal

UnplannedUnplannedDAPT withdrawal≠≠

fre

ed

om

fro

m S

T (

%)

3-6%

/year

Mauri et al. N Engl J Med 2007;356:1020 Roy et al. Am J Cardiol 2009;103:801Kimura et al. Circulation 2009;119:987

Bleeding

Surgery

Peptic ulcer

Bleeding

Surgery

Peptic ulcer70%!70%!

Latib et al, Am J Cardiol 2008;102:1477–1481

Reasons for premature Reasons for premature DAPTDAPT discontinuation discontinuation

Bleeding

Surgery

Peptic ulcer

Bleeding

Surgery

Peptic ulcer70%!70%!

Latib et al, Am J Cardiol 2008;102:1477–1481

Reasons for premature Reasons for premature DAPTDAPT discontinuation discontinuation

Rossini et al, Am J Cardiol 2011;107:186–194

Kimura et al. Circulation 2009;119:987

J-Cypher Registry (10.778 pts)

Only Thienowithdrawal

Only Thienowithdrawal

ASA + ThienoASA + Thienowithdrawalwithdrawal

Eisenberg, et al. Circulation 2009;119:1634

161 161 pts withpts withdefinite STdefinite ST

ASA+Thieno(simultaneous)

ASA+Thieno(sequential)

Thieno only

10 d

ays

10 d

ays

>3

mo

nth

>3

mo

nth

unplannedunplannedDAPT withdrawal

Stent

thrombosis

Bleed, Surgery, Ulcer

ASA + Thieno withdrawalTransfusion, Cancer: “thrombophilic state”

prolongedprolongedDAPT

Kimura et al. Circulation 2009;119:987

J-Cypher Registry (10.778 pts)

6-month landmark analysis

Kimura et al. Circulation 2009;119:987

ACS vsvs Non-ACS

Roy et al. Am J Cardiol 2009;103:801

WHC Registry (2.889 pts)

Clopidogrel treatment duration (days)

Ris

k o

f S

T a

t 4

years

Schulz et al. Eur Heart J 2009;30:2714

6816 pts

Airoldi et al. Circulation 2007;116:145

0.3%/year0.3%/year

2%/y

ear

Stent thrombosis (3021 pts)

BleedingBleeding

Latib et al. Am J Cardiol 2008;102:1477

Latib et al. Am J Cardiol 2008;102:1477

Bleeding & OutcomeBleeding & Outcome

ACC 2011

EXCELLENT trial (1428 pts)EXCELLENT trial (1428 pts)

2013 pts

2013 pts

...tailored...tailored DAPTDAPT duration? duration?

2010guidelines

2010guidelines

DES type&

stent thrombosis

DES type&

stent thrombosis

9-month strut coverage after PPCI (46 pts)

Fan et al. Am J Cardiol 2010;105:972

0

2

4

6

8

10

ZES

% u

ncovere

d s

tru

ts

p=NS

BMS

OCTAMI trial (44 pts)

OCT uncovered struts 6 month after PPCI

Guagliumi, Musumeci et al. JACC Cardiovasc Interv 2010;3:680

BMS

old old -DES

new new -DES

SCAAR registry: stent thrombosisstent thrombosisSCAAR registry: stent thrombosisstent thrombosis

DES for ISR(3-month OCT)

DESERT trialDESERT trial

OCT:6-month

strut coverage

Population Protocol End point Population Protocol End point

DES15 pts with de novode novo lesion

15 pts withISR after BMS

risk

ST without DAPT

bleeds with DAPT

time1 mo 3 mo 6 mo 1 year

DAPT durationDAPT duration

current practice

DAPT durationDAPT duration

Accelerated reendothelizationAccelerated reendothelizationwith 2with 2ndnd generation DES? generation DES?

Maj

or b

leed

ing

(%

)

Sibbing D et al, J Thromb Haemost 2010

Sibbing D et al, J Thromb Haemost 2010

over-respondersmajor bleedings

Response variability to clopidogrelResponse variability to clopidogrel

risk

ST without DAPT

bleeds with DAPT

time1 mo 3 mo 6 mo 1 year

DAPT durationDAPT duration

current practice

DAPT durationDAPT duration

• Over-respondersOver-responders• Haemorrhagic diatesisHaemorrhagic diatesis• Prasugrel, Ticagrelor?Prasugrel, Ticagrelor?

Parodi et al, JAMA 2011; 306:1215-1223.

high

lowresidual

platelet reactivity

1789 ptsp<0.002

Mortality & platelet reactivity after ACSMortality & platelet reactivity after ACSca

rdia

c m

ort

alit

y,

%

ST without DAPTST without DAPT

bleeds with DAPTbleeds with DAPT

• Multiple stenting

• Left main stentingri

sk

time1 mo 3 mo 6 mo 1 year

DAPT durationDAPT duration

current practice

DAPT durationDAPT durationDAPT durationDAPT duration

• Thrombophillic state, low-responders

• Uncovered/malapposed struts at OCT?

Parodi et al, JAMA 2011; in press.

high

lowresidual

platelet reactivity

1789 ptsp<0.002

Mortality & platelet reactivity after ACSMortality & platelet reactivity after ACSca

rdia

c m

ort

alit

y,

%

0

2

4

6

8

10

12

14

16

18

20

card

iac m

ort

ality

, %

thienopyridinedose-adjustmentthienopyridine

dose-adjustment

low high

residual platelet reactivity

P= NS

ConclusioniConclusioniConclusioniConclusioni

Aderenza alla DAPT

cruciale nei primi 30gg!

Dopo 6 mesi la sospensione isolata di clopidogrel non è correlata, né quantitativamente né temporalmente, alla ST.

La durata ottimale della DAPT potrebbe variare in funzione del tipo di DES, fattori clinici, complessità anatomica della PCI.

Sospensione DAPT dopo 30 gg: - pianificata ≠ non pianificata - solo thieno ≠ ASA + thieno

ConclusioniConclusioniConclusioniConclusioni

ConclusioniConclusioniConclusioniConclusioni

...e la durata ottimale DAPT...e la durata ottimale DAPT

con Ticagrelor o Prasugrel?con Ticagrelor o Prasugrel?