CLASIFICACIN SCA

SINDROME CORONARIO AGUDO

ACTUALIZACIN 2014
GUAS AHA/ACC SCASEST 2014

NUEVAS EVIDENCIAS ANTIAGREGANTES

Dr. Iaki Lekuona
S Cardiologa HGU
Osakidetza

SCASEST vs SCACEST

European Heart Journal (2011) 32, 29993054

ESTRATEGIA INICIAL SCASEST

European Heart Journal (2011) 32, 29993054

PRESENTACIN CLNICA SCASEST

European Heart Journal (2011) 32, 29993054

ELECTROCARDIOGRAMA SCASEST

European Heart Journal (2011) 32, 29993054

BIOMARCADORES SCASEST

European Heart Journal (2011) 32, 29993054

PRUEBAS NO INVASIVAS SCASEST

European Heart Journal (2011) 32, 29993054

VALORACIN DEL RIESGO INDIVIDUAL

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

European Heart Journal (2011) 32, 29993054

MARCADORES DE RIESGO SCASEST

European Heart Journal (2011) 32, 29993054

CAUSAS DE ELEVACIN DE Tn EN SCASEST

European Heart Journal (2011) 32, 29993054

ANTIAGREGANTES PLAQUETARIOS EN SCASEST

European Heart Journal doi:10.1093/eurheartj/ehu160 2014

PLATO SCASEST

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

SCASEST o non-STEMI

Indicadores primarias
Cambios dinmicos ST, elevacin 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, 29993054

ESTRATIFICACIN DEL RIESGO TIMI AHA 2014

ESTRATIFICACIN SCASEST AHA 2014

10.1016/j.jacc.2014.09.017

BIOMARCADORES SCASEST AHA 2014

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 FUNCIN DEL RIESGO

10.1016/j.jacc.2014.09.017

TRATAMIENTO ANTISQUMICO SCASEST

European Heart Journal (2011) 32, 29993054

TRATAMIENTO ANTIPLAQUETARIO SCASEST

European Heart Journal (2011) 32, 29993054

TRATAMIENTO ANTIPLAQUETARIO SCASEST

European Heart Journal (2011) 32, 29993054

TRATAMIENTO ANTICOAGULANTE SCASEST

European Heart Journal (2011) 32, 29993054

ESTRATEGIA INVASIVA SCASEST

European Heart Journal (2011) 32, 29993054

POBLACIONES y SITUACIONES ESPECIALES SCASEST

European Heart Journal (2011) 32, 29993054

ESTRATEGIA INVASIVA SCASEST

European Heart Journal (2011) 32, 29993054

TRATAMIENTO ANTICOAGULANTE EN SCASEST non-STEMI

European Heart Journal (2011) 32, 29993054

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

COI DISCLOSURE FOR DR. MONTALESCOT are availalble @ http://www.action-coeur.org

 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 pretreatment with clopidogrel, prasugrel or ticagrelor vs.
no pre-treatment.

ACCOAST design
NSTEMI + Troponin 1.5 times ULN local lab value
Clopidogrel naive or on long term clopidogrel 75 mg
n~4100 (event driven)

Randomize 1:1
Double-blind

CABG
or
Medical
Management
(no more prasugrel)

Prasugrel 30 mg

Placebo

Coronary
Angiography

Coronary
Angiography

Prasugrel 30 mg

Prasugrel 60 mg

PCI

PCI

CABG
or
Medical
Management
(no prasugrel)

Prasugrel 10 mg or 5 mg (based on weight and age) for 30 days

1 Endpoint: CV Death, MI, Stroke, Urg Revasc, GP IIb/IIIa bailout, at 7 days
Montalescot G et al. Am Heart J 2011;161:650-656

1 Efficacy End Point @ 7 + 30 days

(All Patients)
15

CV Death, MI, Stroke,

UR, GPIIb/IIIa Bailout
Pre-treatment
10.8

Pre-treatment
10.0

Endpoint (%)

10

No Pre-treatment
10.8
No Pre-treatment
9.8

Hazard Ratio, 1.02

(95% 0.84, 1.25)
P=0.81

Hazard Ratio, 0.997

(95% 0.83, 1.20)
P=0.98

0
0

No. at Risk, Primary

Efficacy End Point:
No pre-treatment
Pre-treatment

10

15

20

25

30

1752
1791

1621
1616

Days From First Dose

1996
2037

1788
1821

1775

1769
1802

1762
1797

All TIMI (CABG or non-CABG) Major Bleeding

(All Treated patients)
5

Hazard Ratio, 1.90

(95% 1.19, 3.02)
P=0.006

Hazard Ratio, 1.97

(95% 1.26, 3.08)
P=0.002

Endpoint (%)

Pre-treatment
2.9

Pre-treatment
2.6
2

All TIMI Major Bleeding

1
No Pre-treatment

1.5

No Pre-treatment
1.4
0

No. at Risk, All TIMI

Major Bleeding:
No pre-treatment
Pre-treatment

10

15

20

25

30

1284
1297

1263
1280

Days From First Dose

1996
2037

1947
1972

1328
1339

1297
1310

1288
1299

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 pretreatment.
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, A.W. vant 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

G. Montalescot, COI are available at www.action-coeur.org

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
Not
estimable

TIA
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 administracin prehospitalaria de
Ticagrelor previo a la ICP en pacientes con
SCACEST es segura pero no mejora la
reperfusin. Sin embargo reduce el riesgo de
trombosis de stent psot ICP

PUBLICACIN DEL ATLANTIC

REGISTRO COMPARANDO CLOPIDOGREL CON PRASUGREL

EN PRCTICA CLNICA EN USA