Master IPA DAPT Course

Enjeux et Perspectives dans la maladie coronaire Autour des antithrombotiques... Pr Gilles LEMESLE USIC et Centre Hémodynamique, CHRU de Lille Institut Pasteur de Lille, UMR 1011 Faculté de Médecine de l’Université de Lille Déclar...

Enjeux et Perspectives dans la maladie coronaire Autour des antithrombotiques... Pr Gilles LEMESLE USIC et Centre Hémodynamique, CHRU de Lille Institut Pasteur de Lille, UMR 1011 Faculté de Médecine de l’Université de Lille Déclaration de liens d’intérêts Honoraires : Amgen, Astra Zeneca, Bayer, Biopharma, Bristol Myers Squibb, Boehringer Ingelheim, Daiichi Sankyo, Lilly, MSD, Novartis, Pfizer, Sanofi Aventis, Servier, The medicine company  Ce que l’on savait... At least 12 months... Du temps du clopidogrel... TRITON PLATO Les guidelines... 013 I2 M TE 17 NS 0 I2 TEM S PLUS de 12 mois ? 2nd co-primary endpoint: stent thrombosis What happened after clopidogrel cessation ? MOINS de 12 mois ?  Randomized studies EXCELLENT (1443 patients – 6 mois vs 12 mois) ≈50% IDM OPTIMIZE (3119 patients – 3 mois vs 12 mois) ≈ 5% IDM SECURITY (1404 patients – 6 mois vs 12 mois) => Aucun IDM RESET (2148 patients – 3 mois vs 12 mois) ≈15% IDM PRODIGY (2013 patients – 6 vs 24 mois) ≈50% IDM ISAR-SAFE (4005 patients – 6 mois vs 9/12 mois) ≈20% IDM ITALIC (2031 patients – 6 mois vs 12 /24 mois) ≈7% IDM I-LOVE-IT-2 (1829 patients – 6 mois vs 12 mois) ≈25% IDM IVUS-XPL (1400 patients – 6 mois vs 12 mois) ≈15% IDM NIPPON (3773 patients – 6 mois vs 18 mois) ≈15% IDM SMART-DATE (2712 patients – 6 mois vs 12 mois) ≈70% IDM Binder et al. Eur Heart J 2015;36:1207-1211 Higher risk of bleeding if DAPT is pursued after 12 months  Natural history after an acute coronary event s !!! th mon a t6 ility t ab S Lagerqvist et al. NEJM 2007 SCAAR Registry  Natural history after an acute coronary event Décès à 5 ans après un infarctus. FAST-MI 2005 Higher event rates up to 3-4 months in STEMI and 6 months in NSTEMI NSTEMI NSTEMI STEMI STEMI Puymirat E. ESC 2015  Natural history after an acute coronary event On what criteria the decision is based ?  What is your goal ? The stent, the atherosclerotic disease or both ? ist ry R eg N OR CO RO Annual risk at 0.8% per year 1/5 of events Lemesle et al. JACC 2017;69(17):2149-2156  The residual ischemic risk Risk of MI ist ry R eg N OR CO RO Lemesle et al. JACC 2017;69(17):2149-2156  The residual ischemic risk Risk of the composite CV death, MI, Stroke istry R eg EACH R Annual risk at 4% per year Abtan et al. Clinical Cardiology 2016;39(11):670–677  t ry The residual ischemic risk gis e Risk of the composite CV death, MI, Stroke R Y R IF L A C STROKE ++++ Vidal-Petiot V, et al. Lancet.  The residual ischemic risk Risk of the composite CV death, MI, Stroke t ry g is R e History of non-coronary vascular intervention R O N RO CO Delsart et al. Eur J Prevent. Cardiol. 2015:22;864-71  Evaluer le risque de TS très tardive Les plus fréquents Les plus puissants D'Ascenzo et al. IJC 2013 Jul 31;167(2):575-84 La mal-apposition dans 1/3 des cas OCT in 64 consecutive patients with VLST Taniwaki et al. Circulation. 2016;133:650-660  The residual ischemic risk Risk of coronary thrombotic events A meta- analysis of 6 Studies SECURITY PRODIGY ITALIC EXCELLENT OPTIMIZE RESET Giustino et al. J Am Coll Cardiol 2016;68:1851–64 The residual ischemic risk DAPT score  Spontaneous bleeding in stable CAD patients O NOR COR Death 20 5 Hamon M, Lemesle G et al. JACC 2016 Cordonnier C, Lemesle G Eur Stroke J 2018 in press  The risk of bleeding istry R eg CH R EA gistry R Re O ON CO R Ducrocq et al. Eur Heart J. 2010;31:1257-65 Hamon M, Lemesle G et al., JACC, 2014;64(14):1430-1436 The risk of bleeding PRECISE-DAPT score  Who should decide ? The General practitioner The interventional Cardiologist The referring Cardiologist When are the different criteria available ?  Who should decide ? The General practitioner – Not involved in such a specific decision to my view  Who should decide ? The General practitioner – Not involved in such a specific decision to my view The interventional Cardiologist – The best person to decide the initial strategy – Very good knowledge of the problematic and very good evaluation of the coronary anatomy – But !! May be not the best person to decide the long-term strategy – Information available at hospital discharge Very good evaluation of the coronary anatomy and that’s it !! No information on long-term risk factor control Most of the time no or poor information on other vascular beds No information on tolerance  Who should decide ? The General practitioner – Not involved in such a specific decision to my view The interventional Cardiologist The referring Cardiologist – To me, the best person to decide the long-term strategy, not only the 2 first years !!! – Information available Poor knowledge on the true coronary anatomy (as compared to the interventional cardiologist), especially if the discharge letter is not detailed enough Good view on long-term risk factor control, Better evaluation of all vascular beds Tolerance of the treatment within the first few months ++++  Conclusion The discharge letter must mentioned the initial strategy that relies on the interventional cardiologist decision – 6 months for scheduled PCI The default strategy – 12 months in case of ACS The discharge letter must also mentioned relevant information on coronary anatomy and procedure +++ If there is a necessity to shorten (in case of high risk bleeding) – It should be mentioned why in the discharge letter, and when stop DAPT – In case of long-term oral anticoagulation, the discharge letter should precise what would be the strategy in the early following months The decision to pursue beyond 6-12 months should be taken at distance by the referring cardiologist and based on – Uncontrolled risk factors – Diffuse atherosclerosis – Tolerance