MD-FM logo

Pr Deepak Bhatt: best combination of drugs after primary PCI

Download Podcasts
Download Podcasts
You can select your prefered subtitle language by using the  CC  button in the player control bar.
English

Professor Deepak Bhatt:

Optimal adjunctive therapy after stenting for acute myocardial infarction

 

 

Sarah:

MD FM, Medical News from around the world with Peter Goodwin

 

 

PETER:

Hello. I’m Peter Goodwin with web radio’s MD-FM Insight. Our in-depth discussion today is about optimal adjunctive therapy after stenting for acute myocardial infarction. 

 

At the recent European Society of Cardiology Congress held in Amsterdam Harvard Professor Deepak Bhatt, Chief of Cardiology at Brigham & Women’s Hospital in Boston Massachusetts gave his recommendations for achieving the best combination of anti-platelet and anti coagulation agents after primary PCI.

So I asked him: to begin with what’s your starting point with your patient?

 

 

Deepak Bhatt:

“Aspirin, of course, is the standard of care and every patient with ST elevation MI, barring an allergy, should get an aspirin: 300 to 325 milligrams to chew and swallow, uncoated aspirin. That is just the universal standard of care.  Beyond that what to use is somewhat controversial. Dual antiplatelet therapy, most experts would agree, is indicated: by that I mean adding to aspirin an agent like clopidogrel. And probably the dose that would be utilised would be 600 mg even though in many parts of the world 300 mg is the labelled or approved dose, but 600 mg of clopidogrel would be the second anti-platelet agent to add to aspirin. Now more recent data have shown that either prasugrel or ticagrelor would be superior to clopidogrel in terms of its anti platelet effect but also on terms of patient outcomes.” 

 

Peter:

Now, though, cangrelor is in the picture isn’t it?

 

Deepak:

“So those are the options on the menu right now. 600 mg of clopidogrel of prasugrel or ticagrelor in addition to aspirin. But potentially in the future, if approved, intravenous cangrelor: as opposed to those oral medications, might be utilised. It’s not that clopidogrel or prasugrel or ticagrelor wouldn’t still be necessary after the procedure but at least immediately before and during the procedure intravenous cangrelor may give the operator some flexibility as it is a fast on-set fast off-set potent agent and those characteristics make it quite desirable in the cath lab.”

 

Peter:

Now: you get to the cath lab and then it used to be clopidogrel 2B3A inhibitors but now a big player seems to be bivalirudin. Can you give me the data on this?

 

Deepak:

“A big shift in care of the ST elevation MI patient, although it’s also been in other subsets, is the use of bivalirudin as the anti-coagulant as opposed to unfractionated heparin: or for that matter as opposed to low molecular weight heparin. And the standard of care of ST elevation MI had evolved to using heparin plus an intravenous glycoprotein 2b3a inhibitor. Not all operators used it because those agents were perceived as expensive, they weren’t available in all parts of the world, largely due to cost issues, and they were associated with increases in major bleeding. Bivalirudin has been studied, in the HORIZONS trial for example, and been shown significantly to reduce major bleeding as compared to unfractionated heparin plus a glycoprotein 2B3a inhibitor and additionally, to me that would be enough, and additionally has been associated with a lower risk for all-cause mortality in the HORIZONS trial. And therefore many operators have switched to using bivalirudin as their preferred anti-coagulant instead of heparin plus a 2b3a inhibitor, or instead of just heparin alone.”  

 

Peter:

Is that, indeed, your recommendation now?

 

Deepak:

“Yes. So assuming one is practising in a healthcare system where bivalirudin is available, and assuming that it’s affordable. Yes, I think the data show that it is superior to heparin plus a glycoprotein 2b3a inhibitor for that end-point we care about most, all-cause mortality.”

 

Peter:

Thrombus aspiration is going rather well, but specifically not all kinds of thrombus aspiration?

 

Deepak:

“So at least the meta-analyses have suggested that manual thrombus aspiration using a catheter to essentially suck out blood clot improves outcomes in patients with ST-elevation MI undergoing stenting. And in my own practice I do that as a matter of routine: it’s relatively simple, doesn’t add much time to the procedure. In most parts of the world in the context of angioplasty and stenting isn’t that expensive to do: so I do recommend it. I must say, though, as a matter of counterpoint to the meta-analyses I alluded to there was trial presented at the European Society of Cardiology, the TASTE trial, that didn’t find a benefit of manual aspiration thrombectomy but I should point out that it was only a 30 day analysis there’s longer term data yet to come and we have to see what that shows: if it shows absolutely no benefit I might change my answer but for the time being I think simple manual thrombus aspiration does add to procedural success.”

 

Peter:

And for reperfusion, primary PCI is now King: but with a difference now because you’ve looked at the different kinds of drug eluting stents?

 

Deepak:

“So drug eluting stents are an important part of PCI. Of course we’ve evolved in PCI from balloon angioplasty to bare metal stents to first generation drug eluting stents but there were some concerns of stent thrombosis, especially in a patient with ST elevation MI. But now we’ve evolved to use second generation drug eluting stents and the data support it such as the EXAMINATION trial published in the Lancet which showed a lower rate of stent thrombosis for a second generation drug eluting stent compared with a bare metal stent. So that, I think, is a really important advance and does change the standard of care, again with the caveat that the particular health system that we’re talking about can afford it because second generation drug eluting stents are more expensive than bare metal stents.”

 

Peter:

And they’re better because there’s less stent thrombosis?

 

Deepak:

“Well there’s a lower rate of stent thrombosis. But what they’re really designed for is a lower rate of stent re-stenosis: so patients are less likely to need a repeat revascularisation procedure. The reduction in stent thrombosis in some respects is a bonus. That is: that wasn’t necessarily anticipated that second generation drug eluting stents would reduce thrombosis. It was anticipated that they would reduce re-stenosis and the two are slightly different in case anyone is confused by that. Stent re-stenosis, typically, is a gradual process occurring over months whereas stent thrombosis is typically a sudden process caused by blood clot formation: and that can be a life-threatening event.”

 

Peter:

So could you summarised those points: what is the optimum approach to primary PCI now?

 

Deepak:

“In a patient with ST elevation AMI, assuming that primary PCI facilities are available, that is the gold standard and treatment of choice. When that decision has been made to perform primary PCI, if at all possible at the ambulance stage or the emergency department aspirin 300 to 325 mg uncoated chew and swallow should be the initial part of the regimen. Beyond that, in addition to other medical therapy, with respect to anti-platelet therapy a second anti-platelet agent should be added: and the choices are 600 mg of clopidogrel which is essentially available world wide in generic, or, in healthcare systems that can afford it, prasugrel or ticagrelor because these are more effective than clopidogrel. And potentially in the future intravenous cangrelor instead of up-fron clopidogrel prasugrel or ticagrelor because it’s a short-acting potent intravenous agent.

Once the anti-platelet therapy is on-board the PCI can be performed: an anti-coagulant needs to be added and bivalirudin, in my opinion, would be the anti-coagulant of choice; and if, for some reason that isn’t possible, then unfractionated heparin plus a glycoprotein 2b3a inhibitor could be utilised. After that anti-thrombotic therapy the next step would be simple manual thrombus aspiration using a catheter to suck out the blood clot that’s there. And after that, stenting, potentially directly stenting, without any balloon angioplasty: and as far as type of stent a second-generation drug eluting stent would be my recommendation. And with that the primary PCI is concluded. The only consideration then is the type of anti-platelet agent to use and clopidogrel, prasugrel ticagrelor can all be used, but again, assuming it could be afforded. Prasugrel or ticagrelor would be preferred because clinical outcomes show superiority over clopidogrel, at least in patients who aren’t at high risk of bleeding. In patients at high risk of bleeding, of course, some caution needs to be utilised before one would employ prasugrel or ticagrelor because theirs bleeding risks are higher.”

 

Dr Deepak Bhatt, Chief of Cardiology at Brigham & Women’s Hospital in Boston in the USA.

 

That's all from MDFM for now. Don’t forget there’s a gold mine of clinical news, with radio, TV and text, at the MD-FM website so do take a look and explore!

 

I’ll be back soon with Sarah Maxwell and the regular edition of MD-FM. So until then from me, Peter Goodwin, goodbye.

 

RSS
Twitter
Facebook

Previous editions

Partnership

Best of Science in Nutrition 2013: Yogurt for a healthier diet (EB & IUNS 2013)

Best of Science in Nutrition 2013: Yogurt for a healthier diet (EB & IUNS 2013)
Url
Go to
with
Danone Institute International