Dapt duration

dual antiplatelet therapy,acute coronary syndrome,percutaneous coronary intervention ,DAPT and oral anticoagulants,invidualised antiplatelet therapy,ppi

1. The optimal timing of initiation and duration of DAPT Magdy El- Masry Prof. of Cardiology Tanta University 2015 Great Debate

2. ? Single-antiplatelet therapy ( SAPT ) versus Dual-antiplatelet therapy ( DAPT ) ? Longer – versus shorter – duration DAPT Answers to difficult questions in DAPT

3. Antiplatelet Agents—Oral P2Y12 Inhibitors ++ +++ + Bleeding Risk

4. Spectrum of Coronary Artery Disease Acute Coronary Syndromes Stable Coronary Artery Disease

5. Moderate to high-risk NSTEACS as defined in PLATO: ≥2 of: (1) ischemic ST changes on ECG; (2) positive biomarkers;and (3) 1 of the following: 60 years of age or greater, previous MI or CABG, CAD > 50% stenosis in 2 vessels, previous ischemic stroke, diabetes,peripheral arterial disease, or chronic renal dysfunction. Canadian Journal of Cardiology 29 (2013) 1334-1345

6. Canadian Journal of Cardiology 29 (2013) 1334-1345 Prasugrel should be avoided in patients with previous TIA or stroke. In patients aged 75 years and older, or body weight <60 kg, prasugrel should be used with caution and a 5-mg dose considered

7. Canadian Journal of Cardiology 29 (2013) 1334-1345 Prasugrel should be avoided in patients with previous TIA or stroke. In patients aged 75 years and older, or body weight <60 kg, prasugrel should be used with caution and a 5-mg dose considered

8. Canadian Journal of Cardiology 29 (2013) 1334-1345 Antiplatelet Therapy Post-CABG

9. ? Single-antiplatelet therapy (SAPT ) ? Dual-antiplatelet therapy (DAPT)  

10. Management of SCAD patients Angina relief Event prevention • β -blockers and/or CCB Ivabradine Long-acting nitrates Nicorandil Ranolazine Trimetazidine • Lifestyle management • Control of risk factors • Aspirin ( if intolerance, consider clopidogrel ) • Statins • Consider ACE inhibitors or ARBs Consider coronary angio → PCI or CABG Short-acting nitrates, plus 1st line 2 nd line ‏   2013 ESC guidelines on the management of stable coronary artery disease.

11. SCAD Medical Elective PCI Elective CABG Single-antiplatelet therapy (SAPT) Dual-antiplatelet therapy (DAPT)  Aspirin (Indefinite Therapy) If aspirin intolerant : Clopidogrel ( Indefinite Therapy) Aspirin plus Clopidogrel BMS : 1 month DES : 6-12 months

12. The Balance between Anti-ischemic Efficacy and Bleeding Risk of Antithrombotic Therapy in PC I

13. Thus, the thousand dollar question is : Where is the sweet spot between ischaemia and bleeding?

14. What is the optimal duration of DAPT after PCI?   Where is the sweet spot between ischaemia and bleeding?

15. Randomized controlled trials investigating less than 12 months of DAPT did not show significant differences in their composite endpoints compared with 12 months or prolonged DAPT. European Heart Journal (2015) 36, 1207–1211

16. Rates of bleeding are consistently higher for prolonged DAPT, reaching statistical significance in some studies European Heart Journal (2015) 36, 1207–1211

17. The appropriate duration of DAPT for patients following placement of a DES remains controversial.

18. The “Will this trial change my practice?” sessions at PCR 2015 Will this trial change my practice ? The Dual Antiplatelet Therapy (DAPT) study – 12 or 30 months of dual antiplatelet therapy after drug-eluting stents Should the DAPT study shift the standard of care from 12 months to 30 months in patients who receive a DES?  Does the increased risk of bleeding essentially offset the benefits? To whom would you recommend continued DAPT? In whom would you avoid it?

19. A call for individualised medicine (precision medicine or personalized  medicine) How long should DAPT be continued ? 3 , 6, 12, 24, 30 months The therapeutic sweet spot between reduced ischaemia and increased bleeding markedly differs between patients. The currently available evidence speaks for individualising the duration of DAPT, taking the patient’s risk for ischaemic and haemorrhagic events into account

20. Pharmacogenomics : Determining the right drug in the right dosage at the right time for each and every patient

21. Personalized Treatment:  Dream or Reality?  Thromb Haemost 2015; 113: 37–52 Pharmacogenomics

22. Ischemic Risk Bleeding Risk Balanced Benefit/Risk Ratio Tailoring antiplatelet therapy : a step toward individualized therapy to improve clinical outcome?

23. Proposed duration of dual antiplatelet therapy after DES (based on individual risk) European Heart Journal (2015) 36, 1207–1211

24. Long-term risk factors for stent thrombosis after PCI Pharmacological factors Patient characteristics Procedural factors - Premature discontinuation of DAPT - Slow metabolizers of the antiplatelet pro-drug - Diabetes - ACS - LV dysfunction - Malignancy - Stent type - Stent undersizing - Incomplete stent expansion - Incomplete apposition - Greater stent length - Side branch stenting - Overlapping stents - Small vessel calibre European Heart Journal (2015) 36, 1207–1211

25. Pharmacological factors Patient characteristics Procedural factors - Prolonged DAPT - Concomitant use of OAC - Age - History of bleeding - Low body weight - ACS - Thrombocytopenia - GI disease - Impaired kidney function - Liver disease - Cerebrovascular accident - Malignanc y Short-term risk factors : - Femoral access, - Large sheath size - No vascular closure device Long-term risk factors: - Unknown Long-term risk factors for bleeding after PCI European Heart Journal (2015) 36, 1207–1211

26. Factors for physicians to consider in determining the optimal duration of DAPT after DES implantation for individual patients Eisen , A. & Bhatt, D. L. (2015) Defining the optimal duration of DAPT after PCI with DES Nat . Rev. Cardiol . doi:10.1038/nrcardio.2015.87

27. Triple Antithrombotic Therapy Dual-antiplatelet therapy ( DAPT ) + Oral AntiCoagulant ( OAC )   Non-VKA oral anticoagulants (NOACs), previously referred to as new or novel OACs

28. Triple Antithrombotic Therapy Risky but sometimes necessary Dual-antiplatelet therapy (DAPT) : Oral AntiCoagulant (OAC) :

29. Triple Antithrombotic Therapy in AF patients with ACS/PCI Issues for Mr. X

30. Joint consensus document :European Heart Journal (2014)

31. Antithrombotic management in NVAF patients with ACS/PCI

32. Non- valvular AF : Stroke risk

33. Elective PCI in SCAD High (CHA 2 DS 2 -VASC ≥2) Moderate (CHA 2 DS 2 -VASC =1 in males ,=2 in women ) Low or moderate (HAS-BLED 0–2) At least 4 weeks (no longer than 6 months) : triple therapy of OAC + aspirin + clopidogrel Up to 12th month : OAC and clopidogrel (or alternatively,aspirin ) Lifelong : OAC ACS High (CHA 2 DS 2 -VASC ≥2) Moderate (CHA 2 DS 2 -VASC =1 in males,=2 in women ) Low or moderate (HAS-BLED 0–2) 6 months : triple therapy of OAC + aspirin + clopidogrel Up to 12th month : OAC and clopidogrel (or alternatively,aspirin ) Lifelong : OAC OAC and clopidogrel

34. Elective PCI in SCAD Moderate (CHA 2 DS 2 -VASC =1 in males,=2 in women) High (HAS-BLED ≥3) 12 months : OAC and clopidogrel Lifelong : OAC ACS Elective PCI in SCAD High (CHA 2 DS 2 -VASC ≥2) Moderate (CHA2DS2-VASC =1 in males,=in women ) High (CHA 2 DS 2 -VASC ≥2) High (HAS-BLED ≥3) 4 weeks : triple therapy of OAC + aspirin + clopidogrel Up to 12th month : OAC and clopidogrel (or alternatively,aspirin ) Lifelong : OAC OAC and clopidogrel

35. For PCI , BMS may be considered to minimize duration of DAPT Class IIb C After coronary revascularization in patients with CHA 2 DS 2 -VASc score ≥2, it may be reasonable to use clopidogrel concurrently with oral anticoagulants but without aspirin Class IIb B

36. The balance  of bleeding and  ischaemic events  in surgical patients after stenting. Issues for Mr. X

37. Surgery in patients on dual antiplatelet therapy

38. Rabeprazole ------------- PARIET Pantoprazole -----------CONTROLOC Omeprazole --------------LOSEC Lansoprazole ----------- LANZOR Esomeprazole --------- NEXIUM

39. ( Circ Cardiovasc Qual Outcomes. 2015)

40. Light transmission aggregometry (LTA)

41. Factors linked to clopidogrel response variability. Thromb Haemost 2015; 113: 37–52

42. A proposed algorithm for personalised antiplatelet treatment with P2Y12 receptor blockers

43. *The PREDICT score might be used when ticagrelor or prasugrel are not available or contraindicated.