CLASIFICACION SICA

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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



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PRESENTACIN CLNICA SCASEST



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ELECTROCARDIOGRAMA SCASEST



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BIOMARCADORES SCASEST



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PRUEBAS NO INVASIVAS SCASEST



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VALORACIN DEL RIESGO INDIVIDUAL


http://www.outcomes-umassmed.org/grace/


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MARCADORES DE RIESGO SCASEST



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CAUSAS DE ELEVACIN DE Tn EN SCASEST



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ANTIAGREGANTES PLAQUETARIOS EN SCASEST


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European Heart Journal doi:10.1093/eurheartj/ehu160 2014


14/61European Heart Journal Doi:10.1093/eurheartj/ehu160 2014

PLATO SCASEST


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Objetivo Primario Todas las causas de muerte


PLATO SCASEST


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Tiempo hasta la hemorragia mayorTiempo hasta hemorragia no dependienteCBAO


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



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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



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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



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TRATAMIENTO ANTIPLAQUETARIO SCASEST



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TRATAMIENTO ANTIPLAQUETARIO SCASEST



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ESTRATEGIA INVASIVA SCASEST



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POBLACIONES y SITUACIONES ESPECIALES SCASEST



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ESTRATEGIA INVASIVA SCASEST



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TRATAMIENTO ANTICOAGULANTE EN SCASEST non-STEMI



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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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CLASIFICACION SICA

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