data: 9 novembre 2012 evento: genova titolo: added value of gpiib/iiia rb in acs autore: stefano...
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Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Il valore aggiuntodegli anti GPIIb/IIIanella terapia delle SCA
Stefano SavonittoStefano Savonitto
Divisione di CardiologiaDivisione di CardiologiaIRCCS Arcispedale S. Maria NuovaIRCCS Arcispedale S. Maria Nuova
Reggio EmiliaReggio Emilia
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
ACS with persistent ST-segment elevation
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Time from symptom onset to reopening of the IRAand myocardial salvage
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Silvain J. JACC 2011;57:1359Silvain J. JACC 2011;57:1359
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Valgimigli M, et alValgimigli M, et al
Prasugrel vs Tirofiban HBD in PCI for STEMIPrasugrel vs Tirofiban HBD in PCI for STEMI
Variability of platelet inhibitory effect30’ after drug administration
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
All-Cause Mortality 1-Year
open label & double-blind, n = 1398
On-TIME-2
Ten Berg J. J Am Coll Cardiol. 2010;55:2446-55.Ten Berg J. J Am Coll Cardiol. 2010;55:2446-55.
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
A: all ptsN= 2,452A: all ptsN= 2,452
B: TRS>3N= 1,229B: TRS>3N= 1,229
C: TRS>3spoke site N= 502
C: TRS>3spoke site N= 502
D: TRS>3spoke site symptomto rand.< 4hN= 397
D: TRS>3spoke site symptomto rand.< 4hN= 397
6.6%6.6%
13.3%13.3%
16.0%16.0%
Herrmann HC. JACC Intv 2009;2:917-24Herrmann HC. JACC Intv 2009;2:917-24
Benefit of facilitated PPCI in high-risk patients presenting at non-PCI centersBenefit of facilitated PPCI in high-risk patients presenting at non-PCI centers
1-year mortality1-year mortality
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Time from symptom onset to reopening of the IRAand myocardial salvage
JACC Intv 2010; 3: 1292-4JACC Intv 2010; 3: 1292-4
ON TIME 2 Ortolani FINESSE
“Educating the public to seek treatment at an early stage… is likely to reduce mortality to a greater degree than pharmacological facilitation before PCI, although translation of this goal to reality in a community setting is and will continue to be extremely difficult.”
“Educating the public to seek treatment at an early stage… is likely to reduce mortality to a greater degree than pharmacological facilitation before PCI, although translation of this goal to reality in a community setting is and will continue to be extremely difficult.”
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Heestermans AACMJ Thrombosis Haemostasis
2009;7:1612 -8
Reduction of early stent thrombosis with pre-hospital high-dose tirofiban in STEMI
Reduction of early stent thrombosis with pre-hospital high-dose tirofiban in STEMI
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Acute Stent Thrombosis
0.3% 0.3%
1.5% 1.5%
HR (95%CI) =HR (95%CI) =5.93 [2.06,17.04]5.93 [2.06,17.04]
P = 0.0002P = 0.0002
16111611 15831583 15801580 15781578 1577157715911591 15871587 15841584 15831583 15831583
Number at riskNumber at riskBivalirudinBivalirudin
UFH+GPIIb/IIIaUFH+GPIIb/IIIa
Def
/Pro
b S
tent
Thr
ombo
sis
(%)
Def
/Pro
b S
tent
Thr
ombo
sis
(%)
0.00.0
0.50.5
1.01.0
1.51.5
2.02.0
2.52.5
3.03.0
3.53.5
Time in HoursTime in Hours
00 66 1212 1818 24 hours24 hours
Bivalirudin monotherapyBivalirudin monotherapy
Heparin + GPIIb/IIIa inhibitorHeparin + GPIIb/IIIa inhibitor
Dangas G. ACC 2009 Scientific Sessions; March 29, 2009; Orlando, FL.
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
1.6%
3.4%
1.5%
1.2%
HR [95%CI] =1.30 [0.54-3.16]P = 0.56
HR [95%CI] =2.11 [1.07,4.17]P = 0.03
1013519
1009 990 969 957 943 863514 497 486 480 474 430
Number at risk600 mg300 mg
Def
/Pro
b S
ten
t T
hro
mb
osi
s (%
)
0
1
2
3
4
5
Time in Days
0 1 30 90 180 270 365
Clopidogrel Loading in Bivalirudin ptsStent Thrombosis 1-Day Landmark Analysis
600mg Clopidogrel
300mg Clopidogrel
Dangas G. ACC 2009 Scientific Sessions; March 29, 2009; Orlando, FL.
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Comparison of changes in platelet aggregation induced between STEMI patients (n=9) and healthy controls (n=10) after a 600 mg clopidogrel loading dose.Comparison of changes in platelet aggregation induced between STEMI patients (n=9) and healthy controls (n=10) after a 600 mg clopidogrel loading dose.
5 mol/l ADP5 mol/l ADP 20 mol/l ADP20 mol/l ADP
Impaired bioavailability of clopidogrel in STEMI patientsHeestermans A, et al Thrombosis Research 2008;122:776-781
Impaired bioavailability of clopidogrel in STEMI patientsHeestermans A, et al Thrombosis Research 2008;122:776-781
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Abciximab for primary PCI in STEMIsignificant mortality reduction
-29%
De Luca G, et al. JAMA 2005;293:1759
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
HORIZONS - Outcome in Patients With HORIZONS - Outcome in Patients With Symptom Onset to Hospital ER Admission Symptom Onset to Hospital ER Admission <<2.2 hrs 2.2 hrs
.
-43%
p=0.03
EMEA. Assesement Report For Angiox. Doc. Ref No.:EMEA/724835/2009. Page 10. www.emea.europa.eu
MA
CE
at
30 D
ays
(%)
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Predictors of no-reflow: the ISAR database
Variable No-reflow
(n =108) Reflow
(n =1032) P value
Left ventricular ejection fraction (%) 48.0 [32.8; 56.9] 50.0 [42.0; 58.0] 0.028 Number of narrowed coronary arteries
0.57
1 39 (36.1) 364 (35.3) 2 29 (26.9) 325 (31.5) 3 40 (37.0) 343 (33.2) Pre-intervention TIMI flow grade <0.001 0 90 (83.3) 564 (54.6) 1 5 (4.6) 109 (10.6) 2 10 (9.3) 189 (18.3) 3 3 (2.8) 170 (16.5) Vessel size (mm) 3.02 [2.65; 3.34] 2.93 [2.58; 3.25] 0.28 Type of intervention 0.96 Stenting 88 (81.5) 843 (81.7) Balloon angioplasty 20 (18.5) 189 (18.3) Pre-procedural abciximab therapy 84 (77.8) 800 (77.5) 0.95
Data are median [25th; 75th %] or number of patients (%)
Ndrepepa J et al. Circ Cardiovasc Interv. 2010;3-27-33
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Troponins elevated or not
ACS without persistent ST-segment elevation
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Patients judged to be at high risk forPatients judged to be at high risk forprogression to MI or deathprogression to MI or death
Patients with recurrent ischemiaPatients with recurrent ischemiaRecurrent chest painRecurrent chest pain
Dynamic ST-segment changesDynamic ST-segment changes((ST-segment depression or transient ST-segment depression or transient
ST segment elevation)ST segment elevation)
Early post infarction unstable Early post infarction unstable anginaangina
Elevated troponin levelsElevated troponin levelsDiabetesDiabetes
Hemodynamic instabilityHemodynamic instabilityMajor arrhythmias Major arrhythmias (VF, VT)(VF, VT)
Patients with recurrent ischemiaPatients with recurrent ischemiaRecurrent chest painRecurrent chest pain
Dynamic ST-segment changesDynamic ST-segment changes((ST-segment depression or transient ST-segment depression or transient
ST segment elevation)ST segment elevation)
Early post infarction unstable Early post infarction unstable anginaangina
Elevated troponin levelsElevated troponin levelsDiabetesDiabetes
Hemodynamic instabilityHemodynamic instabilityMajor arrhythmias Major arrhythmias (VF, VT)(VF, VT)
Introduction ofGpIIB/IIIA blocker
andCoronary angiography
ESC NSTEACS GUIDELINES YEAR 2002ESC NSTEACS GUIDELINES YEAR 2002
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
GP IIb-IIIa Blockade Before and After PCI: CAPTURE, PURSUIT, PRISM-PLUS
0%
2%
4%
6%
8%
10%
PCI
N=2754 P=0.001
N=12,296P=0.001
+24 h +48 h +72 h +24 h +48 h
Boersma E, et al. Lancet. 2002;359:189-198.
4.3%
2.9%
8.0%
4.9%
Dea
th o
r M
I
Before PCI Post-PCI
Placebo
GP IIb-IIIa inhibitor
0
-33% -39%
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Impact of early intervention in HR ptsWith NSTEACS: the TIMACS study
Mehta SR, NEJM 2009;360:2165-75
30% of the ptsGRS >140)
Risk of Death, MI or stroke
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
<24h >24-48h >48-72h >72h
% p
ts u
nder
goin
g an
giog
raph
y 100-
80-
60-
40-
20-
0-11 11 15
6260
2010 10
Hub hosp (N=165)
Spoke hosp (N=222)
Time to angiography among NSTEACS ptsIn hub and spoke hospitals of the Reggio Emilia province
Savonitto S et al. GIC 2012;13:157-68
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
CV
D/M
I/S
tro
ke
Time From Randomization
0.5 0.4
0%
4%
5%
24 hr 48 hr 72 hr 0-7 Days
PlaceboN=6303ClopidogrelN=6259
1%
1.11.4
0.91.2
3%
2%
2.52.1
RR=0.80p=NS
RR=0.81p=NS
RR=0.85p=NS
RR=0.82p=NS
CURE: Early Impact of Clopidogrel in UA/NSTEMI
Yusuf S. Circulation 2003;107:968
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Clopidogrel Pretreatment: Events in UA/NSTEMI Before Cardiac Catheterization
n = 206 n = 68
PCI-CURE (Median time to Catheterization = 10 Days)
n = 159 n = 47
PlaceboClopidogrel
RR=0.6895% CI (0.47-0.99)
p=0.04
RR=0.76 95%CI (0.62-0.93)
p=0.008
% P
atie
nts
MI or Refractory Ischemia
MI
Mehta SR et al. Lancet 2001;358:527-533
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
van der Heijden et al. JACC 2004; 44:20
Clopidogrel Pre-Treatment and Myocardial Damage After Elective Stenting
3,3 3,26,3 7,4
17,220,4
43,3
51,1
0
10
20
30
40
50
60
%
CK-MB > 16 (6-8 h) CK-MB > 16 (16-24 h) Troponin>0.2 (6-8h) Troponin>0.2 (16-24h)
No Pre-TreatmentClopidogrel Pre-Treatment (3 days)
N = 203
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
28.1
7166.7
0
20
40
60
80
100
Pre-PCI Post-PCI
TM
PG
0/1
(%
)T
MP
G 0
/1 (
%)
6.2
35.5
20
0
10
20
30
40
50
Tissue Level Perfusion by TMPG pre and post-PCI
UpstreamUpstreamTirofibanTirofiban
HBDTirofiban
Abciximab
p=0.015
TM
PG
0/1
(%
)T
MP
G 0
/1 (
%)
UpstreamUpstreamTirofibanTirofiban
HBDHBDTirofibanTirofiban
AbciximabAbciximab
P= 0.0009
Bolognese L et. JACC 2006;47:522
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Giugliano RP. N Engl J Med 2009;360:2176-90Giugliano RP. N Engl J Med 2009;360:2176-90
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
What Early ACS really showed?
1. The trial compared early vs delayed eptifibatide, rather
than GPIIB/IIIa and control
2. Only 59% of the pts underwent PCI, and drug therapy was
strikingly different between North America and Europe (pre-
PCI clopid 50% NA, 85% Europe)
1. The trial compared early vs delayed eptifibatide, rather
than GPIIB/IIIa and control
2. Only 59% of the pts underwent PCI, and drug therapy was
strikingly different between North America and Europe (pre-
PCI clopid 50% NA, 85% Europe)
Giugliano RP. N Engl J Med 2009;360:2176-90Giugliano RP. N Engl J Med 2009;360:2176-90
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Giugliano RP. N Engl J Med 2009;360:2176-90Giugliano RP. N Engl J Med 2009;360:2176-90
What Early ACS really showed?
PE: D+MI+ recurrent ischemia requiring urgent revasc, or thrombotic bailout at 96 hPE: D+MI+ recurrent ischemia requiring urgent revasc, or thrombotic bailout at 96 h
SE: D+MI at 30 daysSE: D+MI at 30 days
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Giugliano RP. N Engl J Med 2009;360:2176-90Giugliano RP. N Engl J Med 2009;360:2176-90
What Early ACS really showed?
PE: D+MI+ recurrent ischemia requiring urgent revasc, or thrombotic bailout at 96 hPE: D+MI+ recurrent ischemia requiring urgent revasc, or thrombotic bailout at 96 h
SE: D+MI at 30 daysSE: D+MI at 30 days
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
death or MI 11.2 vs 12.3 0.89 (0.79–1.01)
0.079
Death 2.8 vs 2.6 1.10 (0.86–1.41) 0.46
Myocardial infarction 9.5 vs 10.6 0.88 (0.77–1.01)
0.073
Death, MI, RI req urg revasc 12.5 vs 13.8 0.89 (0.79–1.01)
0.065
RI req urg revasc 2.4 vs 2.9 0.80 (0.62–1.03) 0.083
death or MI 11.2 vs 12.3 0.89 (0.79–1.01)
0.079
Death 2.8 vs 2.6 1.10 (0.86–1.41) 0.46
Myocardial infarction 9.5 vs 10.6 0.88 (0.77–1.01)
0.073
Death, MI, RI req urg revasc 12.5 vs 13.8 0.89 (0.79–1.01)
0.065
RI req urg revasc 2.4 vs 2.9 0.80 (0.62–1.03) 0.083
30-day Primary Efficacy Resultsafter shrinking the power
Delayed Eptifibatide
(n=4684)
Early Eptifibatide
(n=4722)
OR (95% CI) P
Giugliano RP. N Engl J Med 2009;360:2176-90Giugliano RP. N Engl J Med 2009;360:2176-90
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
30-day Death or MI
0.7 0.80.5 0.6 0.9 1 2
Overall 11.2 12.3
Men 11.4 12.0
Women 10.7 13.0
Age < 75 yr 10.2 11.6
14.0 14.6
Troponin positive 11.6 13.0
Troponin negative 8.1 8.4
Diabetes 11.7 13.8
No Diabetes 10.9 11.7
Early clopidogrel intended 10.3 12.0
No early clopidogrel intended 13.7 13.4
Baseline Characteristic
Early Eptifibatide Better Delayed Provisional Eptifibatide Better
Age > 75 yr
Odds Ratio for UpstreamEptifibatide (95% CI)
Routine Early Eptifibatide, %
Delayed Provisional
Eptifibatide, %
Giugliano RP. N Engl J Med 2009;360:2176-90Giugliano RP. N Engl J Med 2009;360:2176-90
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Medical Only (N=1706)Total Events = 71
CABG (N=251)Pre-CABG Events = 22Post CABG Events = 46
PCI (N=2723)Pre-PCI Events = 87
Post-PCI Events = 243
Medical Only (N=1784)Total Events = 71
CABG (N=268)Pre-CABG Events = 33Post-CABG Events = 52
PCI (N=2666)Pre-PCI Events = 82
Post-PCI Events = 201
Total Events on Medical Treatment = 71 + 82 +33 Total Events on Medical Treatment = 71 + 87 +
22
Group Events Risk Rate Group Events Risk Rate
Medical 186 4718 4.1% Medical 180 4680 4.0%
Post PCI 201 2584 8.0% Post PCI 243 2636 10.5%
Post CABG 52 235 23.4% Post CABG 46 229 20.6%
Medical Only N=3490 PCI N=5389
CABG N=519
Medical Only N=3490 PCI N=5389
CABG N=519
Strategy During First 96 HoursStrategy During First 96 Hours
RandomizationN=9406
Delayed Provisional Eptifibatide (N=4680)Total Events = 469
Early Eptifibatide (N=4718)Total Events = 439
-24%-24%
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Impact of abciximab on top of ASA and clopidogrel
Death or MI at 30 days
Kastrati A, NEJM 2004, JAMA 2006
20-20-
18-18-
16-16-
14-14-
12-12-
10-10-
8-8-
6-6-
4-4-
2-2-
0-0-Placebo AbciximabPlacebo Abciximab Placebo AbciximabPlacebo Abciximab Placebo AbciximabPlacebo Abciximab
4.04.04.04.0 4.04.04.04.0 4.64.64.64.6 4.64.64.64.6
13.113.113.113.1
18.318.318.318.3
ISAR REACT 1ISAR REACT 1 ISAR REACT 2ISAR REACT 2TnT negativeTnT negative
ISAR REACT 2ISAR REACT 2TnT positiveTnT positive
P=0.98P=0.98P=0.91P=0.91
-28%-28%P=0.02P=0.02
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Giugliano RP. N Engl J Med 2009;360:2176-90Giugliano RP. N Engl J Med 2009;360:2176-90
Bleeding events
Early eptifibatide
N=4722
Early eptifibatide
N=4722
Delayed eptifibatide
N=4684
Delayed eptifibatide
N=4684
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Contemporary recommendations on Antiplatelet therapy in NSTEACS PCI
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
ACC/AHA NSTEACS GuidelinesACC/AHA NSTEACS Guidelines
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
ACC/AHA NSTEACS GuidelinesACC/AHA NSTEACS Guidelines
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
How would you treat this patient?
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Probability of 30-D death by sum of ST depressionon the admission ECG: the GUSTO IIb ECG corelab
0
0,05
0,1
0,15
0,2
0,25
0,3
0,35
0 5 10 15 20 25 30 35 40 45
sum of ST depression (mm)
Pro
bab
ilit
y o
f 30
-day
dea
th
Probability of death
95% confidence limits
Savonitto S et al: Eur Heart J 2005;26: 2106
1+2 Q(n=2493)
3 Q(n=1366)
4 Q(n=1333)
50-
40-
30-
20-
10-
0-
% 3-vessel disease
% LM disease
Incidence of 3VD and LMCA diseaseby quartiles of ST depression
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
The Lipsia NSTEACS randomised trial
Thiele H. Eur Heart J 2012;33:2035
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
ACUITY: Invasive Management
UFH/Enoxaparin + GP IIb/IIIa(N=4,603)
Bivalirudin + GP IIb/IIIa
(N=4,604)
Bivalirudin alone
(N=4,612)
Angiography 99.2% 98.8% 98.9%
Adm. to angio (h) 19.7 (7.0-29.3)† 19.5 (7.0-28.2)† 19.8 (7.3-29.0)†
Drug* to angio/interv (h) 5.6 (1.6-22.5)† 5.0 (1.4-21.4)† 5.2 (1.5-22.5)†
Actual procedure
PCI 55.6% 56.7% 56.8%
CABG 11.9% 10.8% 10.6%
Medical therapy 32.4% 32.5% 32.6%
†median (IQR)
Stone GW, Presented at 2006 ACC Meeting.Available at www.Clinicaltrialsresults.orgStone GW, Presented at 2006 ACC Meeting.Available at www.Clinicaltrialsresults.org
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Berger JS. JACC 2008;52:1693
Predictors of reoperation in ACS patients undergoing CABG
Clopidogrel <5 days
4.601 1.454-14.554 0.009
Pre-op aspirin
0.616 0.109-3.483 0.584
Pre-op
GPI
1.825 0.504-6.613 0.360
Prior
CABG
5.299 1.050-26.734 0.043
Odds ratioOdds ratio 95% CI95% CI P-valueP-value
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Outcome300mg Loading Dose
(n=148)>600mg Loading Dose
(n=48) P
Major bleeding, 70 (47%) 35 (73%) 0.002
Re-operation for bleeding,
7 (5%) 6 (12%) 0.09
Tamponade 4 (3%) 2 (4%) 0.64
Mean 24h Chest tube loss
391 ± 251 mL 536 ± 354 mL 0.01
Post-operative MI 8 (5%) 5 (11%) 0.31
Post-operative CVA 6 (4%) 1 (2%) 0.34
LOS in surgical intensive care, days
4.3 ± 4.1 5.0 ± 3.1 0.0001
In-hospital death 7 (5%) 1 (2%) 0.68
Clopidogrel loading dose and bleeding in NSTEACS patients undergoing urgent CABG
Cruden NL. Am Heart J 2011;161:404
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Transfusions from time of CABG
Any transfusion
0.88 (0.67, 1.16)Platelets
1.03 (0.88, 1.20)PRBC or whole blood*
0.83
Transfusions within 7 days post-CABG
0.98 (0.85, 1.14)
Fresh frozen plasma 1.05 (0.84, 1.31)
0.69
0.37
0.67
Transfusions post CABG-related bleeding
1.25 (0.70, 2.23)>5 units whole blood/PRBC (2 days)
1.12 (0.83, 1.53)>4 units blood
Chest tube output >2L (24 hours)
1.24 (0.61, 2.52)
0.45
0.49
0.62
Ticagrelor better Clopidogrel better
0.5 1.0 2.00.2*Median (range) units transfused within 7 days post-CABG:
tic 3.0 (2.0–4.0) vs. clop 3.0 (2.0–4.0); p=0.86
p-valueHazard/Odds Ratio (95% CI)Ticagrelor(n=632)
Clopidogrel(n=629)
15.3 17.3
52.7 51.2
55.2 55.8
25.2 24.0
4.9 4.0
17.9 16.2
3.3 2.7
Characteristic
Held C, JACC 2011;57:672
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Time from CABG to CV death
0 1 2 3 4 5 6 7 8 9 10 11 12
8
7
6
5
4
3
2
1
0
Months from CABG procedure
HR: 0.52 (95% CI = 0.32–0.85), p<0.01
7.9
4.1
Clopidogrel (n=629)
Ticagrelor (n=629)
K-M
est
imat
ed r
ate
(%)
Held C, JACC 2011;57:672
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Smith PK. JACC 2012; epub ahead of print 24 May 2012
Bleeding and mortality after isolated CABGClopidogrel vs prasugrel
mean 12-h chest tube blood loss (655 + 580 ml vs. 503 + 378 ml; p 0.050)
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Event rates for patient undergoing CABG in PURSUIT (< 72 h of GP IIb/IIIa discontinuation)
Marso SP et al; Circulation 2000;102:2952-8
15%15%
35%35%
00 3030 6060 9090 120120 150150 180180
days from randomizationdays from randomization
33.633.6%%
23.8%23.8%
RRR RRR 30%30%
p = p = 0.0020.002
25%25%
cum
ulat
ive
inci
denc
e (%
)cu
mul
ativ
e in
cide
nce
(%)
placeboplacebo
eptifibatideeptifibatide
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Caso clinico 13 settembre 2012Caso clinico 13 settembre 2012
•Uomo di 72 anni senza precedenti cardiovascolari né rilevanti fattori di rischio.•Maratoneta amatoriale fino a un anno fa.
• Il 12 settembre esegue nel nostro Ospedale intervento di litotrissia endovescicalee vaporizzazione prostatica “green light laser” per calcolosi vescicale e IPB ostruente
• Lo stesso pomeriggio, lieve epigastralgia durata 15 minuti, a risoluzione spontanea
• Visita cardiologica (sintomatologia aspecifica) + ECG – richiesti enzimi cardiaci
• La mattina successiva, CKMB 75 ng/ml• Evoluzione ECG
•Uomo di 72 anni senza precedenti cardiovascolari né rilevanti fattori di rischio.•Maratoneta amatoriale fino a un anno fa.
• Il 12 settembre esegue nel nostro Ospedale intervento di litotrissia endovescicalee vaporizzazione prostatica “green light laser” per calcolosi vescicale e IPB ostruente
• Lo stesso pomeriggio, lieve epigastralgia durata 15 minuti, a risoluzione spontanea
• Visita cardiologica (sintomatologia aspecifica) + ECG – richiesti enzimi cardiaci
• La mattina successiva, CKMB 75 ng/ml• Evoluzione ECG
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Data: 9 Novembre 2012
Evento: Genova
Titolo: added value of GPIIb/IIIa RB in ACS
Autore: Stefano Savonitto
Caso clinico 13 settembre 2012Caso clinico 13 settembre 2012
•Uomo di 72 anni senza precedenti cardiovascolari né rilevanti fattori di rischio.•Maratoneta amatoriale fino a un anno fa.
• Il 12 settembre esegue nel nostro Ospedale intervento di litotrissia endovescicalee vaporizzazione prostatica “green light laser” per calcolosi vescicale e IPB ostruente
• Lo stesso pomeriggio, lieve epigastralgia durata 15 minuti, a risoluzione spontanea
• Visita cardiologica (sintomatologia aspecifica) + ECG – richiesti enzimi cardiaci
• La mattina successiva, CKMB 75 ng/ml• Evoluzione ECG • Flectadol 500 mg – Trasferimento in UTIC• Eseguita coronarografia: occlusione trombotica coronaria destra distale• Eseguita tromboaspirazione + POBA con ottimo risultato angiografico
• Tirofiban 24 ore post-procedura in vista di stenting 17 Settembre.
•Uomo di 72 anni senza precedenti cardiovascolari né rilevanti fattori di rischio.•Maratoneta amatoriale fino a un anno fa.
• Il 12 settembre esegue nel nostro Ospedale intervento di litotrissia endovescicalee vaporizzazione prostatica “green light laser” per calcolosi vescicale e IPB ostruente
• Lo stesso pomeriggio, lieve epigastralgia durata 15 minuti, a risoluzione spontanea
• Visita cardiologica (sintomatologia aspecifica) + ECG – richiesti enzimi cardiaci
• La mattina successiva, CKMB 75 ng/ml• Evoluzione ECG • Flectadol 500 mg – Trasferimento in UTIC• Eseguita coronarografia: occlusione trombotica coronaria destra distale• Eseguita tromboaspirazione + POBA con ottimo risultato angiografico
• Tirofiban 24 ore post-procedura in vista di stenting 17 Settembre.