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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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The Second Antiplatelet… CCS 2023
ACS Key points
Ticagrelor preferred (conditional)
– vs clopidogrel greater efficacy, no
increased bleeding risk
If patient is High bleeding risk
– DAPT for 1-3 months non-inferior to
longer durations
• “practice point” – if stepdown to SAPT
choose P2Yinhibitor over ASA
• Step-down to SAPT should incorporate
cardiologist – (eg) avoid if high risk PCI or
hx stent thrombosis
29
SIHD = stable
ischemic heart
disease
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CCS 2023 Antiplatelet Guideline Updates : 1 Slide “All you need to know”
Scenario Drug Preference DAPT duration Alternative regimen Notes
1
o
Prevention No antiplatelet! (HTN Canada, CDA, CCS, Stroke all agree)
Stable CAD,
elective PCI
ASA + Pre Procedure
2h+ clopidogrel 600mg
HBR: 1-3 mos
Standard: 6 mos ASA+ clopidogrel
Extend: up to 3yrs ASA+ clopidogrel
Other P2Yi not studied
extensively in this setting
HBR = high bleeding risk
Individualize duration
based upon pt factors
ACS without
PCI
ASA + Ticagrelor
“shared care decision”
HBR: 1-3 mos DAPT then SAPT
SAPT = P2Yi or ASA
Standard: 1 yr DAPT
ASA+ Ticagrelor 90 BID or
ASA+ Prasugrel 10 OD [*do not pick
if no PCI, prefer ticagrelor here]
Extend : Up to 3yrs
ASA+Ticagrelor 60 BID (dose
reduced)
or ASA + clopidogrel 75mg OD
Or ASA + prasugrel 10mg OD
ASA + clopidogrel
preferred over ASA +
prasugrel (=↑ bleed)
Type I MI, not applicable
to “demand ischemia” /
type 2
NSTEMI + PCI
PCI in <24h*
(*dream-on,
right?)
Load with ASA in ER
Load with P2Yi in cath
lab
180mg ticagrelor or
60mg prasugrel
ASA + clopidogrel Pre-treatment P2Yi load
does not reduce 30d
MACE, does ↑ TIMI
bleeding… but in Canada
most pts wait >24h for
cath with NSTEMI…
NSTEMI + PCI
PCI in >24h
ASA + ticagrelor load in
ER (180mg)
ASA + clopidogrel 600mg
load in ER
STEMI ASA + P2Yi prior to cath
If TNK: Clopidogrel
If no TNK: dealer’s
choice if 1
o
PCI
Post PCI: load 180mg
ticagrelor or
60mg prasugrel load
30
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CCS 2023 Pearls… ACS à CABG
• If you strongly suspect CABG will be required, can withhold P2Yi prior to Angiogram
even if expected delay >24h post ACS
• Stopping P2Yi prior to CABG
– Limited evidence… “multidisc team” to decide, hold 2-7d pre-op
• Suggest hold Ticagrelor 2-3 days rather than 5-7d [weak, conditional]
• Postop Antiplatelet Regimen
– Off-pump – favour DAPT, with ASA + ticagrelor/prasugrel over ASA + Clopidogrel
– On-pump – favor SAPT
– AFIB? – consider OAC monotherapy
We think this is beyond scope of GIM – usually our exam
questions pertain to NON CARDIAC SURGERY!
31
BONUS
Read on own
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The Second Antiplatelet… Nuances
• Ticagrelor is contraindicated if history of:
– intracranial hemorrhage
– active pathological bleeding
– moderate-severe hepatic impairment
– combinations with CYP34A inhibitors (ketoconazole, clarithromycin, ritonavir)
– Should consider avoiding in patients with evidence of heart block or bradycardia.
– Dose: 180mg load then 90 mg bid x 12 months then 60mg bid thereafter
• Prasugrel is contraindicated if:
– active bleeding
– prior TIA/stroke [even ISCHEMIC stroke]
– hypersensitivity reaction
– Dose: 60mg load then 10mg daily (reduce to 5mg if <60kg)
• Ticagrelor & Prasugrel have NOT been adequately evaluated in the setting of
fibrinolysis
in STEMI à Use clopidogrel pre-PCI
CCS Antiplatelet 2023,
CCS AFIB 2020
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Reperfusion Therapy - NSTE-ACS
Timing & risk stratification are the major differences vs. STEMI
1. Risk stratify using clinical judgment + risk scores (TIMI, GRACE)
- Do not memorize these, but understand what factors involved
2. Int/high risk patients: early invasive strategy (angiogram within
48hr)
- Early invasive reduces risk of rehospitalization for ACS but NO
mortality benefit
3. Low risk patients and/or unclear diagnosis: non-invasive testing
(often with functional imaging) reasonable to determine
benefit of invasive strategy
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PCI
• Plain-Old-Balloon-Angioplasty (POBA)
– Rare
• Bare metal stent (BMS) – rarely used
– Endothelialize quickly = lower risk of stent thrombosis after 4+ weeks
– But…higher risk of re-stenosis
• Drug eluting stent (DES) – standard of care
– Elute anti-proliferative agents
– Lower rates of restenosis vs. BMS = can be used in smaller vessels, CABG grafts
– But…take longer to endothelialize
• Drug coated balloon (DCB)
– Expand a blood vessel and deliver antiproliferative agents (e.g. Paclitaxel) without delivering
a stent
– Useful for in-stent restenosis (ISR), bifurcating/branch lesions, buying time for definitive
treatment
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Stents and DAPT Durations
(without AF)
POST ACS (STEMI or NSTEMI/UA): Aim for 12 months of DAPT
– ACS DAPT= ASA + Ticagrelor 90 BID or Prasugrel 10 OD (preferred over ASA+Clop)
• *NEW* CCS 2023: If High Risk of Bleeding with PCI post ACS, can de-escalate to SAPT after 1-3 months
of DAPT OR de-escalate from a more potent second antiplatelet (i.e. change from ASA+ticagrelor to
ASA+clopidogrel)
• Reassess bleeding at 1 year.
– If HIGH RISK bleed: SAPT ASA 81 or Clopidogrel 75
– If LOW RISK bleed: Continue DAPT - Good evidence for up to 3 years (DAPT trial)
DAPT After 12 months: Suggest ASA + one of:
• Ticagrelor (60
mg po bid) (reduced dose, not standard dose)
• Clopidogrel (75 mg po daily)
• Prasugrel (10mg po daily) (weaker recommendation that others for extended therapy)
Non-ACS situations (ELECTIVE PCI)
• High Risk of Bleeding:
Elective PCI DAPT = ASA 81+ Clopidogrel 75
– BMS = DAPT for 1 month then SAPT with ASA 81 or Clopidogrel 75 indefinitely
– DES = DAPT for 3 months then SAPT with ASA 81 or Clopidogrel 75 indefinitely
• Not at high risk of bleeding: DAPT for 6 months, then reassess
– If High Risk thrombotic events: extend DAPT up to 3 yrs
– If not at high risk of thrombosis or if now at high risk bleeding: SAPT (ASA or Clop)
CCS Antiplatelet 2018,2023
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CCS 2023 Antiplatelet Guideline
Update – what’s new?
N.B. all of these recommendations are weak unless otherwise specified
• No routine usage of ASA for primary prevention (but shared decision making with patient if they are
high ASCVD risk and low bleeding risk)
• Shorter DAPT (1-3 months) is now acceptable for patients at high bleeding risk regardless of ACS or
elective (previously ACS would be 12 months minimum)
• Clearer guidance for who is at “High Bleeding Risk” and “Complex PCI” – see following slides. As with
previous versions, changes to DAPT duration will be guided by bleeding and thrombotic risk.
• Medically managed ACS (i.e. no PCI performed):
**N.B. they do not comment on duration, generally 12 months
– Ticagrelor preferred over clopidogrel (weak recommendation)
– Clopidogrel preferred over prasugrel (strong recommendation)
• Pre-treatment with DAPT prior to angiography (recommendations made because DAPT can delay
CABG for days if a patient needs CABG, or increases bleeding risk in urgent/emergent CABG:
– STEMI: give second antiplatelet before angiogram
– NSTEMI: if angiogram anticipated within 24 hours of presentation, can hold off giving second antiplatelet. If >24h
expected before cath, give second antiplatelet
– Elective angiogram: do not routinely treat with second antiplatelet
CCS Antiplatelet 2023
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CCS 2023 Antiplatelet Guideline:
AFIB + Antiplatelets
N.B. all of these recommendations are weak unless otherwise specified. Align w
CCS AFIB guidelines.
• Antiplatelet and anticoagulation (i.e. patient on OAC for atrial
fibrillation)
– Dual pathway (clopidogrel+OAC) recommended over previous
strategy of triple therapy for 1-30 days in most patients (but the small
text says they need to receive 1 dose of ASA at PCI time, so it is like
they only received 1 dose of triple therapy)
– OAC monotherapy preferred over OAC+aspirin in stable CAD (from the
AFIRE trial which showed rivaroxaban+ASA had more bleeding with no
reduction on ischemic events compared to rivaroxaban alone)
CCS Antiplatelet 2023
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High bleeding risk patient
Need 1 major
1. Advanced CKD (eGFR<30)
2. Liver cirrhosis with portal HTN
3. Active malignancy (except melanoma) in the last 12mo and
undergoing treatment
4. Spontaneous bleeding with hospitalization or transfusion in last
6 mo or anytime if recurrent; chronic bleeding diathesis
5. Hb<110, thrombocytopenia PLT<100
6. Prior spontaneous/traumatic ICH <12mo
7. Brain AVM/stroke<6mo
8. Anticipated use of longterm anticoagulation (excluding
COMPASS riva)
9. Non-deferable major surgery on DAPT
10. Recent major surgery/trauma <30d before PCI
Or 2 minor:
1. Moderate CKD (eGFR 30-59)
2. Spontaneous bleeding with hospitalization
or transfusion <12mo not meeting major
criterion
3. Hb 110-129 men/110-119 w omen
4. Any ischemic stroke not meeting major
criterion
5. Long term NSAID/steroids
6. Age>75
Adapted from Figure 2
CCS Antiplatelet 2023
*NEW* CCS 2023 Antiplatelet guidelines give clear
guidance as to who is high risk of bleeding. Meeting
1 major or 2 minor should trigger you to consider a
shorter duration or de-escalated regimen of DAPT
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