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Atrial fibrillation and acute myocardial infarction:
antithrombotic therapy and outcomes
Lopes RN, et al. Am J Med. 2012;125:897-905.
3.9%
9.2%
Prognostic Impact of Types of Atrial
Fibrillation in Acute Coronary Syndromes
Lau DH et al. Am J Cardiol. 2009;104:1317-1323.
Death
Prognostic Impact of Types of Atrial
Fibrillation in Acute Coronary Syndromes
Lau DH et al. Am J Cardiol. 2009;104:1317-1323.
Death, MI, stroke
Triple Therapy With Aspirin, Prasugrel, and Vitamin K
Antagonists in Patients With Drug-Eluting Stent
Implantation and an Indication for Oral Anticoagulation
Sarafoff N, et al. JACC. 2013;61:2060-2066.
Triple Therapy With Aspirin, Prasugrel, and Vitamin K
Antagonists in Patients With Drug-Eluting Stent
Implantation and an Indication for Oral Anticoagulation
Sarafoff N, et al. JACC. 2013;61:2060-2066.
Triple Therapy With Aspirin, Prasugrel, and Vitamin K
Antagonists in Patients With Drug-Eluting Stent
Implantation and an Indication for Oral Anticoagulation
Sarafoff N, et al. JACC. 2013;61:2060-2066.
Triple Therapy With Aspirin, Prasugrel, and Vitamin K
Antagonists in Patients With Drug-Eluting Stent
Implantation and an Indication for Oral Anticoagulation
Sarafoff N, et al. JACC. 2013;61:2060-2066.
Concomitant use of warfarin and ticagrelor as an alternative to
triple antithrombotic therapy after an acute coronary syndrome
Braun OO, et al. Thrombosis Reseach. 2015;135:26-30.
Warfarin and ticagrelor
Concomitant use of warfarin and ticagrelor as an alternative to
triple antithrombotic therapy after an acute coronary syndrome
Braun OO, et al. Thrombosis Reseach. 2015;135:26-30.
Warfarin and ticagrelor
Concomitant use of warfarin and ticagrelor as an alternative to
triple antithrombotic therapy after an acute coronary syndrome
Braun OO, et al. Thrombosis Reseach. 2015;135:26-30.
Warfarin and ticagrelor
AVK NACO
Thrombolyse ou PCI
Abord radial
Dose Charge anti-aggrégants
:
- oui/non
- Si oui lesquels ?
HNF
Protection gastrique
Bitherapie ou tritherapie
Durée
Long Terme
Management of acute coronary syndrome in
patients with non-valvular atrial fibrillation: results
of the EuropeanHeart Rhythm Association Survey
Potpara TS, et al. Europace. 2014;16:293–298
Dewilde WJ, et al. Lancet. 2013;381:1107-1115.
Cumulative incidence of the secondary endpoint (death, myocardial
infarction, stroke, target-vessel revascularisation, and stent thrombosis)
WOEST study investigators
AVK NACO
Thrombolyse ou PCI
Oui Oui
Abord radial Oui Oui
Dose Charge anti-aggrégants
:
- oui/non
- Si oui lesquels ?
Oui Clopidogrel
Oui Clopidogrel
HNF INR < 2 Relai HNF puis
AVK ?
Protection gastrique Oui Oui
Bitherapie ou tritherapie Type stent Type stent
Durée
Long Terme
Madame X, 80 ans, FA depuis 20 ans, ATCD AIT, embolie
MIG, STEMI …, INR 1.9
Radiale, Thrombectomie, stent
Que faite vous après ?
• AVK ou ADO ? • Risque saignement
• Risque ré-IDM
• Impact de l’âge
• Traitements associés
• Aspirine oui/non
• Protection gastrique
Capodanno d, et al. Circ Cardiovasc Interv. 2014;7:113-24
Antiplatelet Therapy for Stable Coronary Artery
Disease in atrial Fibrillation Patients Taking an Oral
Anticoagulant
A Nationwide Cohort Study
Lamberts M, et al. Circulation. 2014;129:1577-1585
Antiplatelet Therapy for Stable Coronary Artery Disease in
atrial Fibrillation Patients Taking an Oral Anticoagulant
A Nationwide Cohort Study
Lamberts M, et al. Circulation. 2014;129:1577-1585
Antiplatelet Therapy for Stable Coronary Artery Disease in
atrial Fibrillation Patients Taking an Oral Anticoagulant
A Nationwide Cohort Study
Lamberts M, et al. Circulation. 2014;129:1577-1585
Major Bleeding
Antiplatelet Therapy for Stable Coronary Artery Disease in
atrial Fibrillation Patients Taking an Oral Anticoagulant
A Nationwide Cohort Study
Lamberts M, et al. Circulation. 2014;129:1577-1585
All cause of death
Apixaban versus Warfarin in Patients with Atrial
Fibrillation
Granger CB, et al. N Engl J Med,. 2011; 365: 981-92
MajorBleeding
Primary Efficacy
A randomized, 2-period, crossover design study to
assess the effects of dexlansoprazole, lansoprazole,
esomeprazole, and omeprazole on the steady-state
pharmacokinetics and pharmacodynamics of
clopidogrel in healthy volunteers
Frelinger AL, et al. J AM Coll Cardiol. 2012;59:1304-1311.
Madame X, 80 ans, FA depuis 20 ans, ATCD AIT, embolie
MIG, STEMI …, INR 1.9
Radiale, Thrombectomie, stent,
Apixaban, aspirine, clopidogrel, pantoprazole
Combination of OAC plus single antiplatelet therapy
(preferably clopidogrel 75 mg/day, or as an alternative, aspirin
75–100 mg/day) may be sometimes continued in very
selected cases, e.g. stenting of the left main, proximal left
anterior descending, proximal bifurcation, recurrent MIs, etc.
(Class IIb, level of evidence B).
RE-DUAL PCI: combination therapy in AF pts undergoing PCI
*Warfarin arm: 1 month after bare metal stent or 3 months after drug-eluting stent
ASA, acetylsalicylic acid; PCI, percutaneous coronary intervention
Adapted from Cannon C. AHA 2013 and Boehringer Ingelheim data on file
Dual primary endpoints: death, MI, stroke/SE, and major bleeding
Patients with NVAF
undergoing PCI (n=8520)
R
Dabigatran 150 mg BID
+ P2Y12 inhibitor
Screening
0–72 hours
after PCI
Dabigatran 110 mg BID
+ P2Y12 inhibitor
Warfarin (INR 2.0–3.0)
+ P2Y12 inhibitor + ASA*
n=2840 patients per arm
Minimum treatment duration: 6 months
Population: Diagnosis of ACS
180 – 360 days
treatment 30-day
follow-up R
Index hospitalization: 1. Acute treatment: invasive or medical management 2. Maintenance dose ASA and P2Y12 inhibitor (clopidogrel, ticagrelor)
Ticagrelor + ASA
SOC
SOC
N=1,500
1:1 N=1,500
Ticagrelor + Rivaroxaban 2.5 mg BID
180 – 360 days
treatment
30-day
follow-up R
Clopidogrel + ASA
SOC
SOC 1:1
Clopidogrel + Rivaroxaban 2.5 mg BID
≤ 24h
Clopidogrel
+ ASA
Ticagrelor
+ ASA
GEMINI ACS 1
ACS study with single vs. dual APs
Short design: Multicentre, prospective,
randomized, double-blind, double-dummy,
active-controlled, parallel-group study
Indication: ACS Start: Q1 2015 LPLV: Q1 2017
www.clinicaltrials.gov/ct2/show/NCT02293395
Objective: Safety of Rivaroxaban in addition to either Clopidogrel or Ticagrelor in ACS
Rivaroxaban Use in Patients With AF Undergoing PCI: PIONEER AF-PCI
• Primary endpoint: TIMI major, minor, and bleeding requiring medical attention
• Secondary endpoint: CV death, MI, stroke, and stent thrombosis
Rivaroxaban dosed at 10 mg once daily in patients with CrCl of 30 to <50 mL/min. †Alternative P2Y12 inhibitors: 10 mg once-daily prasugrel or 90 mg twice-daily ticagrelor.
‡Low-dose aspirin (75-100 mg/d).
2100 patients with NVAF
No prior stroke/TIA
PCI with stent placement
R A N D O M I Z E
1,6, or 12 months
Rivaroxaban15 mg qd* Clopidogrel 75 mg qd†
Rivaroxaban 15mg qd Aspirin 75-100 mg qd
Rivaroxaban 2.5 mg bid Clopidogrel 75 mg qd†
Aspirin 75-100 mg qd‡
VKA (target INR 2.0-3.0) Aspirin 75-100 mg qd
VKA (target INR 2.0-3.0) Clopidogrel 75 mg qd†
Aspirin 75-100 mg qd
≤72
hours
After Sheath removal
1,6, or 12 months
End of treatment at
12 months
AF + ACS/PCI Study
► Randomizations to:
1. Apixaban or a VKA (INR 2.0–
3.0)
2. With or without ASA (all
patients get a P2Y12
antagonist)
OAC P2Y12 including ticagrelor / prasugrel
ASA No ASA
Apixaban 5mg BID 5 mg BID
VKA
therapy
INR 2.0–3.0 INR 2.0–3.0
Academic Research Organization:
Duke Clinical Research Institute (DCRI)
39