Acs focus on dapt
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This document discusses antiplatelet therapy for acute coronary syndromes. It provides information on dual antiplatelet therapy using aspirin and P2Y12 inhibitors like clopidogrel, prasugrel, and ticagrelor. It summarizes trials comparing these drugs and outlines treatment strategies and duration of dual antiplatelet therapy based on a patient's risk level. Factors influencing response to clopidogrel and the potential additional mechanisms of action of ticagrelor are also reviewed.
Acs focus on dapt
- 1. Magdy El-Masry. Prof. of Cardiology. Tanta University.
- 2. Initial assessment of patients with suspected acute coronary syndromes “Other cardiac” includes, among other, myocarditis, Tako-Tsubo cardiomyopathy, or tachyarrhythmias. “Non-cardiac” refers to thoracic diseases such as pneumonia or pneumothorax. If the initial evaluation suggests aortic dissection or pulmonary embolism, D-dimers and MDCT angiography are recommended
- 3. STEMI time delays (Time is Myocardium ) “You may delay, but time will not, and lost time is never found again.” Patient Delay System Delay FMC door-to-balloon time door-to-needle time
- 4. Selection of NSTE-ACS treatment strategy and timing according to initial risk stratification.
- 5. Dual Anti-Platelet Therapy (DAPT)
- 6. Pathophysiology of ACS: The Role of Platelets
- 8. Comparative pharmacokinetics of oral P2Y12 inhibitors. Time to peak platelet inhibition
- 9. Available P2Y12 blockers DAPT (ASA + clopidogrel/prasugrel/ticagrelor) is recommended after ACS (STEMI or NSTE-ACS) to reduce the risk of thrombosis
- 10. Factors linked to clopidogrel response variability. Thromb Haemost 2015; 113: 37–52
- 11. Figure 3. Conceptualizeddistinctionbetween pharmacological response to therapy and treatment failures. Michelle O’Donoghue, and Stephen D. W iviott Circulation. 2006;114:e600-e606 Copyright © American Heart Association, Inc. All rights reserved.
- 12. PLATelet inhibition and patient Outcomes (PLATO) trial. Ticagrelor vs clopidogrel in patients with acute coronary syndromes. Acute Stroke Or Transient IsChaemic Attack TReated With Aspirin or Ticagrelor and Patient OutcomES"SOCRATES"
- 13. The PLATO Trial (Ticagrelor vs Clopidogrel) 1998 2011
- 16. All-cause death in the ticagrelor and clopidogrel arms of the PLATO trial. Percentages are Kaplan–Meier estimates of the rate of the endpoint at 12 months. Mortality rates are reported in the overall population, in subgroups of patients undergoing either planned invasive or conservative strategy
- 18. Canadian Journal of Cardiology 29 (2013) 1334-1345 Based on the PLATO results, the 2012 Canadian Cardiovascular Society Antiplatelet Guidelines recommend the following:
- 19. *Moderate to high-risk NSTEACS as defined in PLATO : ≥ 2 of: (1) ischemic ST changes on electrocardiogram; (2) positive blomarkers; and (3) 1 of the following: 60 years of age or greater, previous MI or CABG, CAD > 50% stenosis in 2 vessels, previous ischemic stroke, diabetes, peripheral arterial disease, or chronic renal dysfunction.
- 20. * Prasugrel should be avoided in patients with previous TIA or stroke. In patients aged 75 years and older, or body weight ≤ 60 kg, prasgurel should be used with caution and a 5 mg dose considered.
- 21. Administration of oral P2Y12 inhibitors prior to coronary angiography has long been the gold standard in patients with ACS. The aim of such a strategy was to allow stent implantation to be performed at a time when platelet activation was reduced to prevent ischemic complications and avoid early stent thrombosis. Pretreatment would also reduce pre-PCI ischemic events by reducing thrombotic burden.
- 24. Initiating Antiplatelet Therapy In Patients With ACS Making decisions in the ER or Cath lab when time matters Loading ticagrelor in patients with ACS is not restricted by
- 26. Ticagrelor is a faster and more potent P2Y12 inhibitor that demonstrated a significant clinical benefit over clopidogrel in ACS. It is therefore recommended as a first-line agent over clopidogrel in ACS Caution in those with a history of COPD, asthma, HF, gout & severe renal impairment due to increased risk of dyspnea & elevated serum uric acid & creatinine.
- 27. Interplay between ticagrelor and adenosine in humans including impact on the heart, lungs, and brain (top); intestine (middle); platelets,kidneys, and liver (bottom). A1, A2A, A2B, and A3 are adenosine receptors potentially involved. Pleiotropic effects of ticagrelor
- 28. Ticagrelor inhibits cellular uptake of adenosine Formation of adenosine and its intracellular uptake and metabolism, which are reduced by ticagrelor through inhibition of ENT1(equilibrative nucleoside transporter 1) Does ticagrelor have additional mechanism(s) of action?
- 29. Potential underlying mechanisms of ticagrelor’s offtarget effects.
- 30. =
- 31. Antiplatelet therapy post-ACS The clinical cardiologist’s role What is the optimal duration of DAPT after ACS? Duration of DAPT in Patients With ACS Treated With Medical Therapy Alone Duration of DAPT in Patients With STEMI Treated With Fibrinolytic Therapy Duration of DAPT in Patients With ACS Treated With PCI Duration of DAPT in Patients With ACS Treated With CABG
- 32. Balanced Benefit/Risk Ratio Sweet spot Ischemic Risk Bleeding Risk
- 36. This study identified a sub-group of patients at high risk of recurrent ischemic events that occurred more than 12 months after an initial MI who could benefit from prolonged DAPT by aspirin and ticagrelor. (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin) trial
- 37. DAPT Risk Score Picks Patients for Extended Therapy 'This is exactly what we need' to balance benefit and risk Continuation of DAPT beyond 1 year reduces the risk of MI and stent thrombosis, with the tradeoff of increased bleeding.
- 38. Using the DAPT Score to Predict Stent Thrombosis vs. Bleeding
- 41. Master Treatment Algorithm for Duration of P2Y12 Inhibitor Therapy in Patients With CAD Treated With DAPT
- 42. Treatment Algorithm for Duration of P2Y12Inhibitor Therapy in Patient With Recent ACS (NSTE-ACS or STEMI)