Gilles Montalescot - appac.fr
Transcript of Gilles Montalescot - appac.fr
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03Gilles MontalescotParis, France
Dr. Montalescot reports research Grants to theInstitution or Consulting/Lecture Fees from Abbott, AIM group, Amgen, Actelion, ACC Foundation, Astrazeneca, Axis-Santé, Bayer, Boston-Scientific, BMS, Beth Israel Deaconess Medical, Brigham Women’s Hospital, FréquenceMédicale, ICOM, Idorsia, Elsevier, ICAN, Lead-Up, Menarini, MSD, Novo-Nordisk, Pfizer, Quantum Genomics, Sanofi-Aventis, SCOR global life, Servier, WebMD.
You can simply impress your audience and add a
unique zing and appeal to your Presentations.
Nos logos
Paris, France www.action-groupe.org
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STENT
Stable/ Stabilisé
STEMI/ACS
ANTICOAG
AC/FA
Valve mécanique
EP/MVTE
SAPL/lupus
Thrombose IC
Accident hemorragique
ou post-op
Situations cliniques multiples
Pas de recette unique
Orientations et principes
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Reconnaitre le HBR
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HBR PCI (one factor or more)
q Elderly age ≥75 years
q OAC planned after PCI
q Renal failure (CrCl <40 ml/min)
q Planned surgery <1 year
q Anemia (Hgb <11 g/dl)
q Hospitalization for bleeding within 1 year
q Thrombocytopenia (<100,000/mm3)
q Cancer diagnosed or treated w/i 3 years
q Stroke within 1 year or any prior ICH
q Severe chronic liver disease
q Long-term NSAID or steroid use
q Expected DAPT non-compliance
• risque ≥ 4% de saignement important (BARC 3 ou 5)ou
• risque ≥ 1% de saignement intracrânien
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Risk of ICH (drug)
ASA+clopià ASA+ticaHR 1.87 (0.98-3.48) - PLATO
ASA+clopià ASA+prasuHR 1.12 (0.58-2.15) - TRITON
ASA+clopià ASA+prasuHR 0.67 (0.28-1.65)- TRILOGY
ASAà ASA+clopiHR 1.42 (1.05-1.92)
ASA+prasuà 0,2%
ASA+ticaà 0,4%
ISAR-REACT5
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Risk of ICH (patient)Intracranial-B2LEED3S
BMI (<25 = 1 point; ≥25 = 0 point) Blood Pressure (high) (Yes = 2 points; No = 0 point)Lacune / small disease (Yes = 1 point; No = 0 point)Elderly (≥75 = 1 point; <75 = 0 point)Ethnicity (Asian = 2 point; Non-Asian = 0 point)Disease Cardiovascular (Yes = 2 points; No = point)Disease Cerebrovascular (Yes = 2 points; No = point)DAPT or anticoagulant (Yes = 1 point; No = point)Sex (Male = 1 point; Female = 0 point)
Amarenco P et al. Cerebrovasc Dis2017;43:145-151
IC B2LEED3 score of ≥5 predicts a ≥1% annual risk of ICH
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Avant et au Cath Lab
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Décisions
01
02
RadialeLow HBR ou urgence
High HBR programmé
Sous A/CPeu d’héparinePas d’antiplaq IV
Sous A/CPeu ou pas d’héparinePas de pré-traitement
Système de fermetureFémorale
Urgence
Programmé
Ponction sous echoPeu d’héparinePas d’antiplaq IV
Discuter arrêt A/C sans relais
Système de fermeture
Ponction sous echoPas de pré-traitement
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Après le Cath Lab
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Le modèle FA et stent
2019201820172016
.
PIONEER AF – PCI 1
Rivaroxaban
AHA 16 ESC 17 ACC 19 ESC 19
2020
None of these trials were powered for efficacy
RE-DUAL PCI 2
Dabigatran
N 2,124 N 2,725
AUGUSTUS ACS/PCI 3Apixaban
2 x 2 factorial
ENTRUST AF- PCI 4,5Edoxaban
Parallel assignment
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ESC Guidelines 2017 à 2020
Hammoudi N, Montalescot G. Eur Heart J 2018
Who are those?
Collet JP, Thiele H et al. ESC NSTE-ACS Guidelines 2020
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Severe Bleeding and Ischemic Outcomes in AUGUSTUSRandomization to 30 Days
Fatal, ICH, Major Bleeding CV Death, Stroke, MI, Stent Thrombosis
J. Alexander. ACC 2020
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Severe Bleeding and Ischemic Outcomes in AUGUSTUS30 Days to 6 Months
Fatal, ICH, Major Bleeding CV Death, Stroke, MI, Stent Thrombosis
J. Alexander. ACC 2020
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MyocardialInfarction
Stent Thrombosis
When shall we drop the antiplatelet agent?
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High ischemic risk...lots of patients
Hammoudi N, Montalescot G. Eur Heart J 2018
Prior Stent thrombosis
Recurrent ACSMultiple/long stents Small arteriesAcute STEMIMultivessel diabetic disease
CHF patientsBifurcations, LM
Last remaining vesselCABG stent
Per-procedure slow-flow
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MASTER-DAPT
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Après la période APT obligatoire (6mois-1an)
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All-cause death: HR 0.55 (0.38-0.81)
Durée de l’aspirine
Yasuda et al. AFIRE - NEJM 2019
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AF patients on OAC therapy (+/- SAPT)History of stent implantation > 12 months
High ischemic risk-Low bleeding risk
OAC alone (population A) OAC+SAPT (population B)
AQUATIC study
R R
Aspirin 100mg Placebo Placebo
Primary safety endpoint: Major bleeding events (ISTH)
Aspirin 100mg
Primary ischemic endpoint : CV death, MI, Stroke, any coronary revasc, systemic embolism, ALI
S* * stratification
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Conclusions Avant et au KT: réduire les risques (hémorragiques)
Dans l’urgence ischémique: garder le bénéfice attendu en tête
Arrêt du dernier antiplaquettaire à randomiser
Stratégies individuelles possibles au cas par cas
01020304
0605
Reconnaitre le haut risque hémorragique
Apres le KT: arrêt rapide de l’aspirine
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Autres possibilitésau cas par cas
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Other options may allow safe DAPT for 1Month
M3 M6M1
Stent thrombosis
Major bleeding
StrokeANTICOAGULANT+SAPT
DAPT
Limbruno U et al. J Clin Med. 2020 Aug; 9(8): 2673.
Hammoudi N, Montalescot G. Eur Heart J 2018
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Reduced DOA dose
Okumura K et al. N Engl J Med 2020; 383:1735-1745
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www.escardio.org/guidelines2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
©ES
C
Figure 7 (1)Algorithm for antithrombotic therapy in non-ST-segment elevation acute coronary syndrome patients without atrial fibrillation undergoingpercutaneous coronary intervention.
Very HBR is defined as recent bleeding in the past month and/or not deferrable planned surgery.
Ongoing bleeding
Medical Angio only
PCI if uncontrolledischemic situation