gencer (switzerland), gerd hasenfuss (germany), keld ... · –to focus on nste-acs only –to...
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www.escardio.org/guidelinesEuropean Heart JournalEuropean Heart Journal
doi:10.1093/doi:10.1093/eurheartjeurheartj/ehu278/ehu278
European Heart JournalEuropean Heart Journaldoidoi: :
2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation
The Task Force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC)
Authors/Task Force Members: Marco Roffi (Chairperson) (Switzerland)*, Carlo Patrono (Co-Chairperson) (Italy)*, Jean-Philippe Collet† (France), Christian Mueller† (Switzerland), Marco Valgimigli† (Netherlands), Felicita Andreotti (Italy), Jeroen J. Bax (Netherlands), Michael A. Borger (Germany), Carlos Brotons (Spain), Derek P. Chew (Australia), Baris Gencer (Switzerland), Gerd Hasenfuss (Germany), Keld Kjeldsen (Denmark), Patrizio Lancellotti (Belgium), Ulf Landmesser(Germany), Julinda Mehilli (Germany), Debabrata Mukherjee (USA), Robert F. Storey (UK), and Stephan Windecker (Switzerland)
www.escardio.org/guidelinesEuropean Heart JournalEuropean Heart Journal
doi:10.1093/doi:10.1093/eurheartjeurheartj/ehu278/ehu278
www.escardio.org/guidelines
Antithrombotic Management
● Goals:– To focus on NSTE-ACS only– To implement novel treatments and strategies– To be exhaustive, consistent and pragmatic
● Major changes : – Pre-treatment in NSTE-ACS– Duration of DAPT– Management of triple therapy
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Preambles
- The choice of the antithrombotic regimen should be based on selected management strategy as well as the chosen revascularisation modality.
- Dosing of antithrombotics should take into account age and renal function.
- Aspirin and parenteral anticoagulation are recommended.
- In conservative strategy without high bleeding risk, ticagrelor (preferred over clopidogrel) is recommended once the NSTEMI is established.
- The optimal timing for ticagrelor (preferred over clopidogrel) initiation in an invasive strategy has not been adequately investigated, while prasugrel is recommended only after coronary angiography prior to PCI.
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Oral Antiplatelet Therapy
Recommendations Antiplatelet therapy Classa Levelb
Oral Antiplatelet Therapy
Aspirin is recommended for all patients without contra-indications at an initial oral loading dose of 150–300 mg (in aspirin naive patients) and a maintenance dose of 75–100 mg daily long-term regardless of treatment strategy.
I A
A P2Y12 inhibitor is recommended, in addition to aspirin, for 12 months unless there are contra-indications such as excessive risk of bleeds.. I A
- Ticagrelor (180 mg loading dose, 90 mg twice daily) is recommended, in the absence of contra-indicationsd, for all patients at moderate-to-high-risk of ischaemic events (e.g. elevated troponins), regardless of initial treatment strategy and including those pretreated with clopidogrel (which should be discontinued when ticagrelor is started).
- Prasugrel (60 mg loading dose, 10 mg daily dose) is recommended in patients who are proceeding to PCI if no contra-indication.
- Clopidogrel (300–600 mg loading dose, 75 mg daily dose) is recommended for patients who cannot receive ticagrelor or prasugrel or who require oral anticoagulation
I B
I B
I B
P2Y12 inhibitor administration for a shorter duration of 3–6 months after DES implantation may be considered in patients deemed at high bleeding risk. IIb A
It is not recommended to administer prasugrel in patients in whom coronary anatomy is not known. III B
Contra-indications for ticagrelor: previous intracranial haemorrhage or ongoing bleeds. Contra-indications for prasugrel: previous intracranial haemorrhage, previous stroke or transient ischaemic attack, or ongoing bleeds; prasugrel is generally not recommended for patients aged 75 years or more or with body weight <60 kg.
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European Society of Cardiology,European Society of Cardiology,London – August 31, 2015London – August 31, 2015
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Anticoagulation during Stenting on OAC
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Antiplatelet Therapy after Stenting on OAC
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Strategies to reduce the bleeding risk
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Cases of the real life
- Treatment initiation according to presentation and risk-profile
- Pre-treatement with P2Y12 inhibitors
- Long-term DAPT
- Triple therapy
- Treatement in specific populations (prior bleeding, prior stroke, AF,…)
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Case #1
A 70-year-old man with NSTEMI underwent PCI with a DES and needs chronic anticoagulation for atrial fibrillation on top of aspirin and clopidogrel. The intern is asking you whether NOACs would be an alternative to VKA for this patient. Yes, NOACS may be used in addition to aspirin and clopidogrel. As the data are scarce, the recommendation is according to expert opinion and the decision should be made on a case by case. The lowest dose of NOACs tested in atrial fibrillation trials should be used (i.e., 110 mg twice a day of dabigatran, 2.5 mg twice a day of apixaban and 20 mg a day of rivaroxaban). More effective P2Y12 inhibitors (i.e. prasugrel or ticagrelor) are not recommended in this setting because of the very high risk of bleeding (section 5.4.1).
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Case #2
A patient on aspirin and prasugrel following left main coronary stenting for NSTE-ACS develops atrial fibrillation lasting more than 24 hours. CHA2DVAS2C score is 2. How do you manage antithrombotic treatment? An option would be to leave the patient on aspirin and prasugrel up to one year given the high risk coronary anatomy. However, since it is likely that atrial fibrillation is going to be permanent, it is advisable to start oral anticoagulation without bridging with parenteral anticoagulation (NOACs have an advantage in this respect over VKA) and to switch from prasugrel to clopidogrel without loading dose (section 5.4.1).
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Case #3
Q22: A 50-year-old patient with unstable angina underwent stenting with a DES of the proximal left circumflex coronary artery. He has chronic anaemia due to ulcerative colitis but no additional co-morbidities. May DAPT duration be shortened to 3 months in this patient?
Yes, the duration of DAPT may be shortened to 3 months in this patient at lower ischaemic risk (e.g. troponin-negative NSTE-ACS), especially if the bleeding risk is high. Accordingly, ischaemic event rates in troponin negative patients are similar to those of patients with stable CAD. In addition, low-risk NSTE-ACS patients have been enrolled in numerous DAPT interruption trials and no excess risk has been identified if a shorter DAPT duration was applied (section 5.2.6).
