OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity...
Transcript of OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity...
![Page 1: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/1.jpg)
September 25, 2020 PRESENTED BY: Joaquin E. CigarroaMD, Clinical Chief, KCVIDivision Head, CardiologyProfessor of Medicine, OHSU
ACS: 2020 Update: A Focus on Bleeding and Bleeding AvoidanceOHSU
![Page 2: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/2.jpg)
2
Conflict of Interest
• NoneOHSU
![Page 3: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/3.jpg)
3
Objectives
• Understand temporal trends during index hospitalization
• Risk stratification• Bleeding and ischemic risk• DAPT and duration• Special populations
OHSU
![Page 4: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/4.jpg)
Temporal Trends of In-Hospital Complications of ACSStahli et al International Journal of Cardiology 2020
OHSU
![Page 5: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/5.jpg)
Temporal Trends in Complications
Recurrent MI Bleeding
9/24/2020 5
OHSU
![Page 6: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/6.jpg)
Temporal Trends
Acute Renal Failure New-onset Atrial Fibrillation
9/24/2020 6
OHSU
![Page 7: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/7.jpg)
Bleeding Risk FactorsESC 2020 ACS Guidelines
9/24/2020 7
OHSU
![Page 8: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/8.jpg)
Bleeding Events Prior to AngiographyRedfors et al JACC 2016
9/24/2020 8
OHSU
![Page 9: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/9.jpg)
9
Bleeding and Management
9/24/2020 9
OHSU
![Page 10: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/10.jpg)
Clinical Case 1
• 72 year old woman with NSTEMI, permanent atrial fibrillation and elevated CHADSVASC score of 3 on a non-vitamin K antagonist develops exertional angina. A stress test is abnormal with high risk features. Coronary angiography demonstrates severe proximal LAD disease and she is treated with a drug eluting stent.
OHSU
![Page 11: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/11.jpg)
Discharge MedicationsA. Aspirin 81 mg daily and P2Y12
inhibitorB. Warfarin and clopidogrel 75 mg dailyC. Rivaroxiban 15 mg daily plus
clopidogrel 75 mg daily D. Dabigatran 150 mg bid plus
clopidogrel 75 mg daily E. Apixaban 5 mg po bid plus clopidogrel
75 mg daily
OHSU
![Page 12: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/12.jpg)
Dual vs Triple Tx in ACS Patients with indication for AC
Gupta et al ACC 2020
9/24/2020 12
OHSU
![Page 13: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/13.jpg)
Management of Antithrombotic Therapy in Atrial Fibrillation Patients Undergoing PCI
JACC State-of-the-Art Review Capodanno et al 109
OHSU
![Page 14: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/14.jpg)
AFIRENEJM 2019
OHSU
![Page 15: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/15.jpg)
Stent Thrombosis in Afib Patients: AugustusLopes et al Circulation
OHSU
![Page 16: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/16.jpg)
Stent Thrombosis in Afib Patients: AugustusLopes et al Circulation
OHSU
![Page 17: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/17.jpg)
Discharge MedicationsA. Aspirin 81 mg daily and P2Y12 inhibitorB. Warfarin and clopidogrel 75 mg dailyC. Rivaroxiban 15 mg daily plus clopidogrel
75 mg daily D. Dabigatran 150 mg bid plus clopidogrel
75 mg daily E. Apixaban 5 mg po bid plus clopidogrel 75
mg daily
OHSU
![Page 18: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/18.jpg)
Atrial Fibrillation Recommendations
1. Double therapy is preferred to triple therapy to reduce hemorrhagic complications without a signal of harm with regards to stent thrombosis.
2. Non-vitamin K antagonists are preferred to warfarin and should be used at doses which are effective to reduce systemic thromboemboli.
3. Patients on double therapy all start on triple therapy for a period of at least periprocedurallyto one month.
4. Reasonable to stop antiplatelet tx at one year.
OHSU
![Page 19: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/19.jpg)
ACS Post PCI
• 76 year old woman with hypertension, hyperlipidemia and Stage 3 CKD is admitted with NSTEMI and treated with DES to the proximal LADOHSU
![Page 20: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/20.jpg)
Discharge Antiplatelets1. Aspirin 81 mg daily plus P2Y12 inhibitor
for 12 months2. Aspirin 81 mg daily plus P2Y12 inhibitor
for 30 months3. Aspirin 81 mg daily and Ticagrelor 90 mg
po bid for 3 month followed by Ticagrelor alone for 15 months
4. Aspirin 75-100 mg daily and ticagrelor 90 mg po bid for one month followed by Ticagrelor 90 mg bid for with 23 months
OHSU
![Page 21: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/21.jpg)
Twilight ACSMehran AHA 2019
OHSU
![Page 22: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/22.jpg)
OHSU
![Page 23: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/23.jpg)
OHSU
![Page 24: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/24.jpg)
OHSU
![Page 25: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/25.jpg)
OHSU
![Page 26: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/26.jpg)
OHSU
![Page 27: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/27.jpg)
Discharge Antiplatelets1. Aspirin 81 mg daily plus P2Y12 inhibitor
for 12 months2. Aspirin 81 mg daily plus P2Y12 inhibitor
for 30 months3. Aspirin 81 mg daily and Ticagrelor 90 mg
po bid for 3 month followed by Ticagrelor alone for 15 months
4. Aspirin 75-100 mg daily and ticagrelor 90 mg po bid for one month followed by Ticagrelor 90 mg bid for with 23 months
OHSU
![Page 28: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/28.jpg)
Summary
1. Bleeding is a common occurrence and is associated with excess morbidity and mortality.
2. Antiplatelet therapy including DAPT is no longer a 12 month standard answer post ACS.
3. Double therapy in patients with Afib should include triple therapy for the first week to minimize stent thrombosis and maybe to one month. Double therapy should be the default and triple therapy should be avoided.
4. Abbreviated DAPT lowers bleeding without signal of excess risk of MACE
OHSU
![Page 29: OHSU · OHSU. Summary 1. Bleeding is a common occurrence and is associated with excess morbidity and mortality. 2. Antiplatelet therapy including DAPT is no longer a 12 month standard](https://reader035.fdocuments.net/reader035/viewer/2022071219/6058bd6664d8fc36a7666d7c/html5/thumbnails/29.jpg)
Thank You!
OHSU