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CLASIFICACIN SCA
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SINDROME CORONARIO AGUDO
ACTUALIZACIN 2014
GUAS AHA/ACC SCASEST 2014
NUEVAS EVIDENCIAS ANTIAGREGANTES
Dr. Iaki LekuonaS Cardiologa HGUOsakidetza
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SCASEST vs SCACEST
European Heart Journal (2011) 32, 29993054
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ESTRATEGIA INICIAL SCASEST
European Heart Journal (2011) 32, 29993054
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PRESENTACIN CLNICA SCASEST
European Heart Journal (2011) 32, 29993054
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ELECTROCARDIOGRAMA SCASEST
European Heart Journal (2011) 32, 29993054
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BIOMARCADORES SCASEST
European Heart Journal (2011) 32, 29993054
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PRUEBAS NO INVASIVAS SCASEST
European Heart Journal (2011) 32, 29993054
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VALORACIN DEL RIESGO INDIVIDUAL
European Heart Journal (2011) 32, 29993054
http://www.outcomes-umassmed.org/grace/
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MARCADORES DE RIESGO SCASEST
European Heart Journal (2011) 32, 29993054
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CAUSAS DE ELEVACIN DE Tn EN SCASEST
European Heart Journal (2011) 32, 29993054
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ANTIAGREGANTES PLAQUETARIOS EN SCASEST
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European Heart Journal doi:10.1093/eurheartj/ehu160 2014
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PLATO SCASEST
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Objetivo Primario Todas las causas de muerte
European Heart Journal doi:10.1093/eurheartj/ehu160 2014
PLATO SCASEST
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Tiempo hasta la hemorragia mayorTiempo hasta hemorragia no dependienteCBAO
European Heart Journal doi:10.1093/eurheartj/ehu160 2014
PLATO SCASEST
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SCASEST o non-STEMI
Indicadores primariasCambios dinmicos ST, elevacin troponinas
Indicadores secundariasDiabetes, GRACE score > 140, FEVI
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PRUEBAS INVASIVAS
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ESTRATIFICACIN DEL RIESGO TIMI AHA 2014
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ESTRATIFICACIN SCASEST AHA 2014
10.1016/j.jacc.2014.09.017
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BIOMARCADORES SCASEST AHA 2014
10.1016/j.jacc.2014.09.017
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10.1016/j.jacc.2014.09.017
TRATAMIENTO SCASEST 2014
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10.1016/j.jacc.2014.09.017
TRATAMIENTO SCASEST 2014
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10.1016/j.jacc.2014.09.017
TRATAMIENTO SCASEST 2014: ANTIAGREGANTES
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10.1016/j.jacc.2014.09.017
TRATAMIENTO SCASEST 2014
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10.1016/j.jacc.2014.09.017
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10.1016/j.jacc.2014.09.017
ESTRATEGIA EN FUNCIN DEL RIESGO
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TRATAMIENTO ANTISQUMICO SCASEST
European Heart Journal (2011) 32, 29993054
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TRATAMIENTO ANTIPLAQUETARIO SCASEST
European Heart Journal (2011) 32, 29993054
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TRATAMIENTO ANTIPLAQUETARIO SCASEST
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ESTRATEGIA INVASIVA SCASEST
European Heart Journal (2011) 32, 29993054
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POBLACIONES y SITUACIONES ESPECIALES SCASEST
European Heart Journal (2011) 32, 29993054
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ESTRATEGIA INVASIVA SCASEST
European Heart Journal (2011) 32, 29993054
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TRATAMIENTO ANTICOAGULANTE EN SCASEST non-STEMI
European Heart Journal (2011) 32, 29993054
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COI DISCLOSUREFORDR. MONTALESCOTare availalble @ http://www.action-coeur.org
G Montalescot, L Bolognese, D Dudek, P Goldstein, C Hamm, JF Tanguay,
JM ten Berg, DL Miller, TM Costigan, J Goedicke, J Silvain, P Angioli,
J Legutko, M Niethammer, Z Motovska, JA Jakubowski, G Cayla,LO Visconti, E Vicaut, P Widimskyfor the ACCOAST investigators
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Pre-treatment with aspirin and a P2Y12antagonist hasbeen a class I recommendation and common practicefor the treatment of NSTE-ACS
However, no trial has ever randomized patientspresenting with NSTE-ACS, invasively managed, to pre-
treatment with clopidogrel, prasugrel or ticagrelor vs.no pre-treatment.
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ACCOAST design
Prasugrel 30 mg
Prasugrel 60 mgPrasugrel 30 mg
Prasugrel 10 mg or 5 mg (based on weight and age) for 30 days
PCI
1 Endpoint: CV Death, MI, Stroke, Urg Revasc, GP IIb/IIIa bailout, at 7 days
Placebo
CoronaryAngiography
n~4100 (event driven)
CoronaryAngiography
PCI
CABG
or
Medical
Management
(no prasugrel)
CABG
or
Medical
Management
(no more prasugrel)
Montalescot G et al. Am Heart J 2011;161:650-656
Randomize 1:1Double-blind
NSTEMI + Troponin 1.5 times ULN local lab valueClopidogrel naive or on long term clopidogrel 75 mg
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Days From First Dose
0 5 10 15 20 25 30
Endpoin
t(%)
0
5
10
15
1996
2037
1788
1821
1775 1769
1802
1762
1797
1752
1791
CV Death, MI, Stroke,UR, GPIIb/IIIa Bailout
1621
1616
No. at Risk, Primary
Efficacy End Point:
No pre-treatment
Pre-treatment
Pre-treatment10.810.0
Pre-treatment
Hazard Ratio, 0.997(95% 0.83, 1.20)P=0.98P=0.81
(95% 0.84, 1.25)Hazard Ratio, 1.02
No Pre-treatment10.8
9.8No Pre-treatment
1 Efficacy End Point @ 7 + 30 days(All Patients)
All TIMI (CABG or non CABG) Major Bleeding
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All TIMI (CABG or non-CABG) Major Bleeding(All Treated patients)
Days From First Dose
0 5 10 15 20 25 30
Endpoin
t(%)
0
1
2
3
4
5
All TIMI Major Bleeding
Pre-treatment2.9
Pre-treatment
2.6
No Pre-treatment1.5
No Pre-treatment1.4
1996
2037
1947
1972
1328
1339
1297
1310
1288
1299
1284
1297
1263
1280
No. at Risk, All TIMIMajor Bleeding:No pre-treatment
Pre-treatment
Hazard Ratio, 1.97(95% 1.26, 3.08)P=0.002
Hazard Ratio, 1.90(95% 1.19, 3.02)P=0.006
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Conclusions
In NSTE-ACS patients managed invasively within 48 hours of admission,pre-treatment with prasugrel does not reduce major ischemic eventsthrough 30 days but increases major bleeding complications.
The results are consistent among patients undergoing PCI supportingtreatment with prasugrel once the coronary anatomy has been defined.
No subgroup appears to have a favorable risk/benefit ratio of pre-treatment.
Reappraisal of routine pre-treatment strategies in NSTE-ACS is needed.
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Administration of Ticagrelor in the cath Lab or in theAmbulance for New STelevation myocardial Infarction to
open the Coronary artery
G. Montalescot, COI are available at www.action-coeur.org
G. Montalescot, A.W. vantHof, F. Lapostolle, J Silvain, J.F. Lassen, L. Bolognese,W.J. Cantor, A. Cequier, M. Chettibi, S.G. Goodman, C.J. Hammett, K. Huber, M. Janzon,
B. Merkely, R.F. Storey, U. Zeymer, O. Stibbe, P. Ecollan, W.M.J.M. Heutz, E. Swahn,
J.P. Collet, F.F. Willems, C. Baradat, M. Licour, A. Tsatsaris, E. Vicaut, C.W. Hamm,for the ATLANTIC investigators
h l l
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In-hospital new oral P2Y12 antagonistsPrimary PCI of STEMI
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Pre-specified clinical 2 endpoints
Composite of death, MI, stent thrombosis,stroke or urgent revascularization at 30 days
Definite stent thrombosis at 30 days
Thrombotic bailout with GPIIb/IIIa inhibitors
d l d d
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Study population and design
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Safety objectives
Bleeding (excluding CABG related events)
PLATO definition
TIMI, STEEPLE, GUSTO, ISTH and BARC definitions Within first 48h and during 30 days of treatment
Other safety events within 30 days of studytreatment
Major adverse CV events
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Major adverse CV eventsup to 30 days
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Definite stent thrombosisup to 10 days
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Definite stent thrombosisup to 30 days
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Clinical endpoints at 30 days
Values are %Odds ratio
(95% CI)p-value
Death (all-cause)1.68
(0.94, 3.01) 0.08
MI 0.73(0.28, 1.94) 0.53
Stroke2.11
(0.39, 11.53) 0.39
TIANot
estimable
Urgent coronaryrevascularization
0.66(0.21, 2.01) 0.46
Bail-out GP IIb/IIIa inhibitors0.80
(0.59, 1.10) 0.17
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Non-CABG-related bleeding events(PLATO definitions) - Safety population
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Conclusion
La administracin prehospitalaria deTicagrelor previo a la ICP en pacientes conSCACEST es segura pero no mejora lareperfusin. Sin embargo reduce el riesgo detrombosis de stent psot ICP
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PUBLICACIN DEL ATLANTIC
REGISTRO COMPARANDO CLOPIDOGREL CON PRASUGREL
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REGISTRO COMPARANDO CLOPIDOGREL CON PRASUGRELEN PRCTICA CLNICA EN USA
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