Learn from Practice : Optimal PCI Treatment for HBR Patients
Transcript of Learn from Practice : Optimal PCI Treatment for HBR Patients
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Learn from Practice : Optimal PCI Treatment for HBR Patients
Wonjae Lee, MD, MBA
International Healthcare Center/
Cardiovascular Center
Seoul National University Bundang Hospital
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Consulting Fees/Honoraria:
N/A
Disclosure
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Table of contents
▪ Short DAPT and for high bleeding risk
▪ DAPT for high ischemic risk
▪ Cases
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More patients are at higher risk for bleeding!
Elderly
patients
CKD
Atrial
Fibrillation
with DOAC
Non-
cardiac
surgeries
Long-term
NSAIDs
use
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ARC-HBR - make up about 40% of the PCI
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Mortality after the occurrence of bleeding is high, and shorter DAPT associated with lower risk
Palmerini T et al. JACC 2017;69(16):2011-22.
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Short DAPT Trials
A Kirtane, Why Onyx One, TCT2019
HOST-REDUCE-POLYTECH-ACS
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STOPDAPT: safety of 3 months DAPT
Cardiovascular Intervention and Therapeutics, July 2016, Volume 31, Issue 3, pp 196–209
Patient: All comer (ACS 32%), PCI, multicenter, single arm RCT (n=1,525)
Intervention: PCI using CoCr-EES, DAPT for 3 months (continue with aspirin)
Non-inferior when compared with RESET group (historical comparison group)
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SMART CHOICE: safety of 3 months DAPT
Patient: All comers (ACS 58% → UA 31%), PCI, multicenter, RCT (n=2,993)
Intervention: PCI using CoCr-EES, PtCr-EES or BP-SES, DAPT for 3 months vs. 12 months
Comparison: DAPT for 3 months (continue with clopidogrel) vs. 12 months
Hahn et al. JAMA. 2019;321(24):2428-2437.
Consistent across various subgroups including clinical presentation(ACS/stable CAD) and type of P2Y12 inhibitors
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STOPDAPT-2: safety of 1 month DAPT
JAMA. 2019;321(24):2414-2427.
Patient: All comer (ACS 38%), PCI, multicenter, RCT (n=3,045)
Intervention: PCI using CoCr-EES, DAPT for 1 months vs. 12 months
Comparison: DAPT for 1 months vs. 12 months
Consistent across subgroups except for the small subgroup of patients with severe CKD
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Need for prolonged DAPT or potent antiplatelet agents?
ACS
Heavy
calcification
Bifurcation DM
LM
disease
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SMART DATE: safety of 6 months DAPT in ACS
Patient: ACS 100% (MI 69%), PCI, multicenter, RCT (n=2,712)
Intervention: PCI, 6 months vs. 12 months or longer DAPT (aspirin + clopidogrel)
Comparison: DAPT for 6 months vs. 12 months or longer DAPT
MACCE ACD
MI Barc 2-5
MACCE ACD
MI Barc 2-5
Hahn JY et al. Lancet 2018; 391: 1274–84
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IDEAL-LM: left main disease for 4 months DAPT
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IDEAL-LM: Definite/Probable Stent Thrombosis
All probable ST
→
“zero definite
ST with Xience”
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Meta-analysis: Duration of DAPT after complex PCI
Patient level pooled analysis
: OPTIMIZE, EXCELLENT, RESET, PRODIGY, ITALIC, and SECURITY
JACC 2016:68:1851-64
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Effect of procedural complexity
Cardiac death, MI, ST Bleeding
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Effect of high risk procedural subset
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Ischemic Benefit on Long-Term DAPT According to the Degree of
PCI Complexity
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STOPDAPT-2 HBR
The benefit of 1-month DAPT in HBR patients was driven
by marked reduction of bleeding
CV death/MI/ST/Stroke TIMI major/minor bleeding
HBR patients also had higher cardiovascular event
rates without difference between 1- and 12-month DAPT.
T Kimura, TCT 2019
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[TICO] Ticagrelor mono therapy group numerically improves MACCE compared to DAPT group
Kim BK et al. JAMA. 2020 Jun 16;323(23):2407-2416.
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Prasugrel-based de-escalation of dual antiplatelet therapy after percutaneous coronary intervention in patients with acute coronary syndrome
(HOST-REDUCE-POLYTECH-ACS)
HS Kim, J Kang et al, Lancet 2020; 396: 1079–89
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Case
▪ M/87
▪ Present illness
▪ Sudden collapse, LOC → 119, BP not measurable, SpO2 70%
▪ Arrived at ER, V/S stabilized, ECG II,III,aVF STE
▪ Past medical history
▪ HBV LC
▪ Chronic alcoholics
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CasemRCA near total occlusion POBA with 3.0x15mm
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CaseOnyx 3.0x18mm Final
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Case
▪ 2 days later, melena with hypotension
▪ EGD: duodenal ulcer bleeding → hemoclipping done
▪ Discharged with aspirin and clopidogrel, PPI
▪ 4 months later, patient visited ER again for melena
▪ Patient was on aspirin and clopidogrel
▪ EGD: ulcer scar
▪ Patient was transferred for further care
▪ Never came back to my clinic….
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Case:
▪ M/82
▪ Present illness
▪ Recent development of chest pain
▪ While waiting for admission, patient collapsed
▪ Past medical history
▪ MDS on treatment (anemia and thrombocytopenia)
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CasemRCA focal 70% stenosis pdLAD diffuse stenosis upto 90%
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CaseOnyx 2.5x18mm Onyx 2.75x15mm
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CaseStill, hypotensive, RI Onyx 2.75x15mm
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CaseFinal
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Case
▪ DAPT was maintained for one month
▪ Changed to Clopidogrel single → thrombocytopenia progressed
▪ Currently on Aspirin qod by hematologist
▪ Admitted to evaluate PAD
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Case1YR F/U CAG
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Case
▪ M/77
▪ Present illness
▪ Exertional chest pain with DOE, 1-2YA
▪ TMT positive, admission for CAG
▪ Past medical history
▪ HTN
▪ PAF
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CasepdLAD diffuse tight stenosis RCA some disease
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CasePOBA with 2.5x20mm Onyx 2.5x30mm
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CaseAdjunctive ballooning after rewiring Final
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Case
▪ DAPT + DOAC was maintained for one month (enrolled in Onyx One Trial)
▪ DOAC + Clopidogrel
▪ After one year, DOAC single has been prescribed
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Case1YR F/U CAG
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Take home message
▪ Shorter DAPT for patient with HBR
▪ Simplify PCI and minimize metal burden for patients with HBR
▪ Shorter DAPT duration or de-escalation strategy with Newer P2Y12
inhibitor can be a solution to mitigate high ischemic risk with HBR
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Thank You for Your Attention!