case-based forum: individualizing antithrombotic therapies ...€¦ · n ecg normal; body weight 64...
TRANSCRIPT
Case-Based Forum: Individualizing
Antithrombotic Therapies for PCI Patients
Sunil V. Rao MD
Disclosures
n No relationships with industry
n American Heart Association – payment for role as Editor-in-
Chief of Circulation: Cardiovascular Interventions
n Off-label uses of drugs or devices may be discussed
Antithrombotic therapy for PCI: what are our goals and priorities?
Goals
n Treat Sx
n Attenuate myocardial damage
n Reduce the risk of recurrent
ischemic events
l Short-term (in-hospital)
l Long-term
Priorities
n Rapid treatment
n Risk stratification
n Balance risk of thrombosis with risk of bleeding
n Integrate strategies into invasive or conservative management
l Recognize duration of treatment course
n Reduce LOS/Costs
What are the existing gaps?
n What is the best APT for elective PCI for stable angina?
n How long should we treat and what drives that decision?
l Presentation?
l Complexity of CAD?
l Number of stents?
l Comorbid conditions (CHF, afib)?
n Should we de-escalate at some point and if so, to what?
l ASA alone?
l P2Y12 alone?
l Rivaroxaban?
Agenda
n Case 1. Stable Outpatient with Suspected Multivessel Coronary Artery Disease Presenting for Diagnostic Coronary Angiographyl Sunil V. Rao, M.D., FSCAI, Duke
University Hospital, Durham, NC
n Case 2. Patient Presents to the ER on Weekend with an NSTEMIl Binita Shah, M.D., FSCAI, New
York University School of Medicine, New York, NY
n Case 3. STEMI Patient With a History of Diabetes Arrives to the ER and Will Require Primary PCIl Timothy D. Henry, M.D., MSCAI,
The Christ Hospital Health Network, Covington, KY
n Case 4. A Patient With a History of Atrial Fibrillation, Already on Warfarin Presents to the ED With Chest Pain and Rules in for NSTEMI. l David A. Cox, M.D., MSCAI,
Cardiovascular Associates, Mountain Brook, AL
Case 1: Stable Outpatient with Suspected Multivessel Coronary Artery Disease Presenting for Diagnostic Coronary Angiography
n 74 yo female presents to your office with exertional chest discomfort of increasing frequency
n History of HTN, prior smoking (quit 20 years ago), abnormal lipids
n ECG normal; body weight 64 kg
n Referred by her PCP who obtained a nuclear exercise stress test
l Exercised into Stage 1 modified Bruce – stopped for chest discomfort
l 2 mm ST-segment depression in II, III, aVF
l Images show large anterior reversibility and mild inferior reversibility
n Treated with ASA, ISDN, SL NTG prn and referred to you
Case 1: Stable Outpatient with Suspected Multivessel Coronary Artery Disease Presenting for Diagnostic Coronary Angiography
n Options?
l Medical therapy and follow-up
l Cath
l CTA
Case #1: Angiography
n Left dominant system
n Significant prox LAD and LPDA stenoses
n Now what?
l CABG?
l Medical Rx?
l PCI?
If PCI, then what strategy?
n Access site – Right Radial
n Anticoagulation?
l UFH
l Bivalirudin
n APT?
l Clopidogrel?
l Prasugrel?
l Ticagrelor?
l Cangrelor prior to oral?
Case #1: Multivessel PCI
n DES X 3
n IVUS guidance
Case #1: Post-PCI
n How long to treat with DAPT?
l 6 months?
l 12 months?
l Indefinitely?
n How would you de-escalate?
l Drop P2Y12?
l Drop ASA?
l Change to rivaroxaban 2.5 mg?
l Change to ticagrelor 60 mg BID?
Case #1: Epilogue
n Uneventful recovery
n Same day discharge
n ASA 81 mg + Clopidogrel 75 mg for 12 months
n Aggressive secondary prevention
n Plan to de-escalate at 12 months to ASA alone if no issues
