ESC Congress 2017 In Review – Focus on CAD&ACS - 19

ESC Congress 2017

In Review

CAD & ACS

Table 3. Maintenance Antithrombotic Strategy After STEMI
Recommendations

Class

Antiplatelet therapy with low-dose aspirin (75-100 mg) is indicated.

DAPT in the form of aspirin plus ticagrelor or prasugrel (or clopidogred if ticagrelor or prasugrel are not available or are contraindicated), is recommended for 12 months after PCI, unless there are contraindications such as excessive risk of bleeding.

Level
A
A

A PPI in combination with DAPT is recommended in patients at high risk of gastrointestinal bleeding.

In patients with an indication for oral anticoagulation, oral anticoagulants are indicated in addition to antiplatelet therapy.

In patients who are high risk of severe bleeding complications, discontinuation of P2Y12 inhibitor therapy after 6 months should
be considered.

IIa

In STEMI patients with stent implantation and an indication for oral anticoagulation, triple therapy should be considered for 1-6
months (according to a balance between the estimated risk of recurrent coronary events and bleeding).

IIa

DAPT for 12 months in patients who did not undergo PCI should be considered unless there are contraindications such as excessive
risk of bleeding.

IIa

In patients with LV thrombus, anticoagulation should be administered for up to 6 months guided by repeated imaging.

IIa

In high ischaemic-risk patients who have tolerated DAPT without a bleeding complication, treatment with DAPT in the form of
ticagrelor 60 mg BID on top of aspirin for longer than 12 months may be considered for up to 3 years.

IIb

In low-bleeding-risk patients who receive aspirin and clopidogrel low-dose rivaroxaban (2.5 mg BID) may be considered.

IIb

The use of ticagrelor or prasugrel is not recommended as part of triple antithrombtic therapy with aspirin and oral anticoagulation.

III

DAPT, dual antiplatelet therapy; LV, left ventricular; PCI, percutaneous coronary intervention; PPI, proton pump inhibitor.
Reprinted from Ibanez B, James S et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation:
The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).
Eur Heart J 2017; doi:10.1093/eurheartj/ehx419. By permission of Oxford University Press on behalf of the European Society of Cardiology.

Use of P2Y12 Inhibitors for
Treatment of Acute Coronary
Syndromes
Written by Nicola Parry

Deepak L. Bhatt, MD, MPH, Harvard Medical School,
Boston, Massachusetts, USA, opened the State of the
Art: P2Y12 Inhibitors in Acute Coronary Syndromes session on 29 August 2017 with a review of some of the
landmark studies of P2Y12 inhibitors, beginning with the
CURE trial. CURE evaluated the efficacy and safety of
clopidogrel plus aspirin in patients with acute coronary
syndromes (ACS) without ST-segment elevation (NSTEACS). Results showed a significant benefit for clopidogrel on the composite endpoint of death from cardiovascular (CV) causes, nonfatal myocardial infarction (MI),
or stroke (RR vs placebo 0.80; 95% CI, 0.72 to 0.90; P
< .001) but at the risk of increased major (but not lifethreatening) bleeding (3.7% vs 2.7%; RR, 1.38; P = .001)
[Yusuf S et al. N Engl J Med. 2001].
Similarly, increased bleeding was noted in the
TRITON trial, which compared prasugrel with clopidogrel
in patients with moderate- to high-risk ACS scheduled
for percutaneous coronary intervention (PCI). Prasugrel
significantly reduced ischaemic risk versus clopidogrel,
but prasugrel increased the risk of major bleeding (HR,
1.32; 95% CI, 1.03 to 1.68; P = .03) and life-threatening
bleeding (1.4% vs 0.9%; P = .01) [Wiviott SD et al. N Engl
J Med. 2007].

For the PLATO trial which compared ticagrelor and
clopidogrel for the prevention of CV events in patients
with ACS with or without ST-segment elevation, Dr Bhatt
noted that ticagrelor significantly reduced the rate of
death from CV causes, MI, or stroke. There was no significant difference in the rates of major bleeding but
ticagrelor was associated with a higher rate of major
bleeding not related to coronary artery bypass grafting
(CABG; 4.5% vs 3.8%, P = .03), including more instances
of fatal intracranial bleeding [Wallentin L et al. N Engl J
Med. 2009].
Patients With NSTE-ACS
Dual therapy with aspirin and a P2Y12 inhibitor has
become standard of care for patients with NSTE-ACS, said
Patrick Riedmaier, MD, Clinic of the City of Ludwigshafen,
Germany. Randomised head-to-head trials comparing the
new P2Y12 inhibitors are lacking, however, and the guidelines do not specify which agent clinicians should choose.
Prof Riedmaier conducted a study to compare the intrahospital efficacy and safety of ticagrelor versus prasugrel
in patients with NSTE-ACS who underwent PCI. The study
was based on data from the German ALKK-PCI registry,
which includes > 16,000 consecutive patients treated with
ticagrelor, prasugrel, or clopidogrel at 40 hospitals in
Germany. Patients treated with clopidogrel were excluded from the analysis. A subanalysis was performed for
patients for whom prasugrel is not recommended (ie, those
with a history of transient ischaemic attack or stroke, aged
≥75 years, and/or body weight < 60 kg; Core Population).

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