the leeds teaching hospitals nhs trust pharmacology in acs overview of the data : practical advice...
DESCRIPTION
The Leeds Teaching Hospitals NHS Trust Pharmacology in ACS Anti-platelet agents Anti-thrombin agents Aspirin Clopidogrel Heparin (UFH, LMWH) ?IIb/IIIa antagonists ?Bivalirudin A and E / ward Cath lab ?Heparin ?BivalirudinTRANSCRIPT
The Leeds Teaching HospitalsNHS Trust
PHARMACOLOGY IN ACSPHARMACOLOGY IN ACS
OVERVIEW OF THE DATA : OVERVIEW OF THE DATA : PRACTICAL ADVICE PRACTICAL ADVICE
JIM McLENACHAN,JIM McLENACHAN,LEEDS.LEEDS. 25th January, 2007
The Leeds Teaching HospitalsNHS Trust
CONFLICT OF INTEREST :
ADVISORY BOARD MEMBER FOR LILLY AND NYCOMED
The Leeds Teaching HospitalsNHS Trust
Pharmacology in ACSPharmacology in ACSAnti-platelet agents Anti-thrombin agents
AspirinClopidogrel
Heparin(UFH, LMWH)
?IIb/IIIa antagonists
?IIb/IIIa antagonists ?Bivalirudin
A a
nd E
/ w
ard
Cat
h la
b
?Heparin
?Bivalirudin
The Leeds Teaching HospitalsNHS Trust
Pharmacology in ACSPharmacology in ACS
AspirinUFH
LMWHIIb/IIIa antagonists
Clopidogrel
Bivalirudin
19951996
1999
2004
The Leeds Teaching HospitalsNHS Trust
ADJUNCTIVE THERAPY IN PCIADJUNCTIVE THERAPY IN PCI
45 year old male with chest painECG – T inversion V1 –V6
Troponin raised
Angiogram - 95% LAD stenosis
PCI to LAD
The Leeds Teaching HospitalsNHS Trust
ADJUNCTIVE THERAPY IN PCIADJUNCTIVE THERAPY IN PCI
45 year old male with chest painECG – T inversion V1 –V6
Troponin raised
Angiogram - 95% LAD stenosis
PCI to LAD
AspirinClopidogrelLMWH
?IIb/IIIa inhibitor
UFH
?IIb/IIIainhibitor
The Leeds Teaching HospitalsNHS Trust
ADJUNCTIVE THERAPY IN PCIADJUNCTIVE THERAPY IN PCI
45 year old male with chest painECG – T inversion V1 –V6
Troponin raised
Angiogram - 95% LAD stenosis
PCI to LAD
AspirinClopidogrelLMWH
?IIb/IIIa inhibitor
UFH
IIb/IIIainhibitor
10am14/1/07
11am14/1/07
2pm14/1/07
2.30pm14/1/07
The Leeds Teaching HospitalsNHS Trust
ADJUNCTIVE THERAPY IN PCIADJUNCTIVE THERAPY IN PCI
45 year old male with chest painECG – T inversion V1 –V6
Troponin raised
Angiogram - 95% LAD stenosis
PCI to LAD
AspirinClopidogrelLMWH
?IIb/IIIa inhibitor
UFH
?IIb/IIIainhibitor
10am14/1/07
10am15/1/07
2pm18/1/07
2.30pm18/1/07
The Leeds Teaching HospitalsNHS Trust
ACUITY STUDYACUITY STUDYDESIGNDESIGN
• 13,819 ACS patients13,819 ACS patients• 3 antithrombotic regimens3 antithrombotic regimens
- heparin + IIb/IIIa inhibitor- heparin + IIb/IIIa inhibitor- bivalirudin + IIb/IIIa - bivalirudin + IIb/IIIa
inhibitorinhibitor - bivalirudin alone - bivalirudin alone • Composite endpointComposite endpoint
- death/MI/unplanned revasc.- death/MI/unplanned revasc.- major bleeding- major bleeding
NEJM 2006;355:2203-16
The Leeds Teaching HospitalsNHS Trust
ACUITY STUDYACUITY STUDYRESULTSRESULTS
HEPARIN +HEPARIN +IIb/IIIa INHIBITORIIb/IIIa INHIBITOR
BIVALIRUDIN +BIVALIRUDIN +IIB/IIIA INHIBITORIIB/IIIA INHIBITOR
COMPOSITECOMPOSITEISCHAEMIAISCHAEMIA
7.3%7.3% 7.7%7.7%
MAJORMAJORBLEEDINGBLEEDING
5.7%5.7% 5.3%5.3%
NET CLINICALNET CLINICALOUTCOMEOUTCOME
11.7%11.7% 11.8%11.8%
NEJM 2006:355:2203-16
The Leeds Teaching HospitalsNHS Trust
ACUITYACUITY
But,
“Angiography was performed in 99% of patients at a median of 19.6 hours after admission……”
The Leeds Teaching HospitalsNHS Trust
ISAR REACT 2ISAR REACT 2DesignDesign
• 2022 ACS patients2022 ACS patients• Pretreated with clopidogrel 600 mgPretreated with clopidogrel 600 mg• Randomised to abciximab or placeboRandomised to abciximab or placebo• Primary composite of death / MI / urgent TVRPrimary composite of death / MI / urgent TVR
JAMA 2006;295:1531-1538
The Leeds Teaching HospitalsNHS Trust
ISAR REACT 2ISAR REACT 2Death / MI / urgent TVR at 30 daysDeath / MI / urgent TVR at 30 days
abciximababciximab placeboplacebo
No troponin elevationNo troponin elevation 4.6%4.6% 4.6%4.6%
Troponin elevationTroponin elevation 13.1%13.1% 18.3% **18.3% **
JAMA 2006;295:1531-1538
The Leeds Teaching HospitalsNHS Trust
“….recommended strategy was an early PCI with stenting within 6 hours from establishment of the diagnosis of ACS”
The Leeds Teaching HospitalsNHS Trust
ADJUNCTIVE THERAPY IN PCIADJUNCTIVE THERAPY IN PCI
45 year old male with chest painECG – T inversion V1 –V6
Troponin raised
Angiogram - 95% LAD stenosis
PCI to LAD
AspirinClopidogrelLMWH
?IIb/IIIa inhibitor
UFH
?IIb/IIIainhibitor
10am14/1/07
10am15/1/07
2pm18/1/07
2.30pm18/1/07
The Leeds Teaching HospitalsNHS Trust
SUMMARYSUMMARY
• STEMI STEMI - aspirin, clopidogrel, abciximab- aspirin, clopidogrel, abciximab• NSTEMINSTEMI - aspirin, clopidogrel, heparin for all- aspirin, clopidogrel, heparin for all
- add IIb/IIIa inhibitor if - add IIb/IIIa inhibitor if early early PCIPCI - - IIb/IIIa inhibitor for high risk PCIIIb/IIIa inhibitor for high risk PCI - - bivalirudin plus IIb/IIIa inhibitor is abivalirudin plus IIb/IIIa inhibitor is a possible possible alternative strategyalternative strategy
The Leeds Teaching HospitalsNHS Trust
MY CONFLICTSOF INTEREST ARE:
Dr McLenachan is Clinical Director of Cardiologyat Leeds General Infirmary and is keen to save money by minimising the use of expensive drugs.