CLASIFICACIÓN SCA
SINDROME CORONARIO AGUDO
ACTUALIZACIÓN 2014
GUÍAS AHA/ACC SCASEST 2014
NUEVAS EVIDENCIAS ANTIAGREGANTES
Dr. Iñaki Lekuona Sº Cardiología HGU Osakidetza
SCASEST vs SCACEST
European Heart Journal (2011) 32, 2999–3054
ESTRATEGIA INICIAL SCASEST
European Heart Journal (2011) 32, 2999–3054
PRESENTACIÓN CLÍNICA SCASEST
European Heart Journal (2011) 32, 2999–3054
ELECTROCARDIOGRAMA SCASEST
European Heart Journal (2011) 32, 2999–3054
BIOMARCADORES SCASEST
European Heart Journal (2011) 32, 2999–3054
PRUEBAS NO INVASIVAS SCASEST
European Heart Journal (2011) 32, 2999–3054
VALORACIÓN DEL RIESGO INDIVIDUAL
European Heart Journal (2011) 32, 2999–3054
http://www.outcomes-umassmed.org/grace/
MARCADORES DE RIESGO SCASEST
European Heart Journal (2011) 32, 2999–3054
CAUSAS DE ELEVACIÓN DE Tn EN SCASEST
European Heart Journal (2011) 32, 2999–3054
ANTIAGREGANTES PLAQUETARIOS EN SCASEST
European Heart Journal doi:10.1093/eurheartj/ehu160 2014
European Heart Journal Doi:10.1093/eurheartj/ehu160 2014
PLATO SCASEST
Objetivo Primario Todas las causas de muerte
European Heart Journal doi:10.1093/eurheartj/ehu160 2014
PLATO SCASEST
Tiempo hasta la hemorragia mayor Tiempo hasta hemorragia no dependiente CBAO
European Heart Journal doi:10.1093/eurheartj/ehu160 2014
PLATO SCASEST
SCASEST o non-STEMI
Indicadores primarias Cambios dinámicos ST, elevación troponinas Indicadores secundarias Diabetes, GRACE score > 140, FEVI <40% Crp <60 ml/min
Riesgo de hemorragia CRUSADE, ACUITY
Acceso radial
PRUEBAS INVASIVAS
European Heart Journal (2011) 32, 2999–3054
ESTRATIFICACIÓN DEL RIESGO TIMI AHA 2014
ESTRATIFICACIÓN SCASEST AHA 2014
10.1016/j.jacc.2014.09.017
BIOMARCADORES SCASEST AHA 2014
10.1016/j.jacc.2014.09.017
10.1016/j.jacc.2014.09.017
TRATAMIENTO SCASEST 2014
10.1016/j.jacc.2014.09.017
TRATAMIENTO SCASEST 2014
10.1016/j.jacc.2014.09.017
TRATAMIENTO SCASEST 2014: ANTIAGREGANTES
10.1016/j.jacc.2014.09.017
TRATAMIENTO SCASEST 2014
10.1016/j.jacc.2014.09.017
10.1016/j.jacc.2014.09.017
ESTRATEGIA EN FUNCIÓN DEL RIESGO
TRATAMIENTO ANTISQUÉMICO SCASEST
European Heart Journal (2011) 32, 2999–3054
TRATAMIENTO ANTIPLAQUETARIO SCASEST
European Heart Journal (2011) 32, 2999–3054
TRATAMIENTO ANTIPLAQUETARIO SCASEST
European Heart Journal (2011) 32, 2999–3054
TRATAMIENTO ANTICOAGULANTE SCASEST
European Heart Journal (2011) 32, 2999–3054
ESTRATEGIA INVASIVA SCASEST
European Heart Journal (2011) 32, 2999–3054
POBLACIONES y SITUACIONES ESPECIALES SCASEST
European Heart Journal (2011) 32, 2999–3054
ESTRATEGIA INVASIVA SCASEST
European Heart Journal (2011) 32, 2999–3054
TRATAMIENTO ANTICOAGULANTE EN SCASEST non-STEMI
European Heart Journal (2011) 32, 2999–3054
COI DISCLOSURE FOR DR. MONTALESCOT are 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 Widimsky for the ACCOAST investigators
● Pre-treatment with aspirin and a P2Y12 antagonist has been a class I recommendation and common practice for the treatment of NSTE-ACS
● However, no trial has ever randomized patients presenting with NSTE-ACS, invasively managed, to pre-treatment with clopidogrel, prasugrel or ticagrelor vs. no pre-treatment.
ACCOAST design
Prasugrel 30 mg
Prasugrel 60 mg Prasugrel 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
Coronary Angiography
n~4100 (event driven)
Coronary Angiography
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 1:1 Double-blind
NSTEMI + Troponin ≥ 1.5 times ULN local lab value Clopidogrel naive or on long term clopidogrel 75 mg
Days From First Dose
0 5 10 15 20 25 30
End
po
int
(%)
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-treatment 10.8 10.0
Pre-treatment
Hazard Ratio, 0.997 (95% 0.83, 1.20) P=0.98 P=0.81
(95% 0.84, 1.25) Hazard Ratio, 1.02
No Pre-treatment 10.8
9.8 No Pre-treatment
1° Efficacy End Point @ 7 + 30 days (All Patients)
All TIMI (CABG or non-CABG) Major Bleeding (All Treated patients)
Days From First Dose
0 5 10 15 20 25 30
End
po
int
(%)
0
1
2
3
4
5
All TIMI Major Bleeding
Pre-treatment 2.9
Pre-treatment 2.6
No Pre-treatment 1.5
No Pre-treatment 1.4
1996 2037
1947 1972
1328 1339
1297 1310
1288 1299
1284 1297
1263 1280
No. at Risk, All TIMI Major 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
Conclusions
● In NSTE-ACS patients managed invasively within 48 hours of admission, pre-treatment with prasugrel does not reduce major ischemic events through 30 days but increases major bleeding complications.
● The results are consistent among patients undergoing PCI supporting treatment 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.
Administration of Ticagrelor in the cath Lab or in the Ambulance for New ST elevation myocardial Infarction to
open the Coronary artery
G. Montalescot, COI are available at www.action-coeur.org
G. Montalescot, A.W. van’t Hof, 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
In-hospital new oral P2Y12 antagonists Primary PCI of STEMI
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
Study population and design
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 study treatment
Major adverse CV events up to 30 days
Definite stent thrombosis up to 10 days
Definite stent thrombosis up to 30 days
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
Stroke 2.11
(0.39, 11.53) 0.39
TIA Not
estimable Urgent coronary revascularization
0.66 (0.21, 2.01) 0.46
Bail-out GP IIb/IIIa inhibitors 0.80
(0.59, 1.10) 0.17
Non-CABG-related bleeding events (PLATO definitions) - Safety population
Conclusion
La administración prehospitalaria de Ticagrelor previo a la ICP en pacientes con SCACEST es segura pero no mejora la reperfusión. Sin embargo reduce el riesgo de trombosis de stent psot ICP
PUBLICACIÓN DEL ATLANTIC
REGISTRO COMPARANDO CLOPIDOGREL CON PRASUGREL EN PRÁCTICA CLÍNICA EN USA