P4786Dual antithrombotic therapy is similarly effective to triple therapy in preventing thrombotic events in patients with atrial fibrillation and acute coronary syndrome

Abstract Background Antithrombotic therapy is effective in preventing ischemic and thromboembolic events, however it simultaneously increases the risk of bleeding. The efforts thus focus on balancing the intensity of combined antiplatelet and anticoagulant therapy. Purpose The study aimed to compare efficacy and safety of single (aspirin/clopidogrel) or dual (aspirin plus clopidogrel) antiplatelet therapy in combination with an oral anticoagulant in non-selected patient population with atrial fibrillation (AFib) and an acute coronary syndrome (ACS). Methods The analysis used data from National Registry of Reimbursed Health Services (NRRHS), which contains data of the entirety of health care paid from the public health insurance (almost 100% of healthcare in the Czech Republic) combined with the database of death records. Occurrence of an ACS, stroke, and bleeding requiring hospitalization within one year was compared in patients discharged on dual and triple antithrombotic therapy. Dual antithrombotic therapy consists of aspirin/clopidogrel plus an oral anticoagulant. Triple antithrombotic therapy was defined as combination of aspirin, clopidogrel and an oral anticoagulant. Results Over a four-year period (2012–2016) 104 000 patients with an ACS were hospitalized in the Czech Republic. AFib (any types) was reported in 12.4% (N=12 891) of them (21.2% in patients 75+ years old). +AFib (vs. −AFib) patients were a higher risk population with respect to the comorbidity (diabetes, hypertension, renal disease, stroke, heart failure) (p&lt;0.05 for all comorbidities). Oral anticoagulant therapy was indicated in 25.3% of them. PCI was performed in 57.7% (−AFib) and 43.4% (+AFib) patients, respectively. Hospital mortality was significantly higher in +AFib patients (8.6% and 5.6%, OR (95% CI): 1.585 (1.481; 1.696), p&lt;0.001). We identified 1017 patients discharged on dual and 967 patients on triple antithrombotic therapy. Risk of recurrent ACS within one year with dual therapy was comparable to that with triple therapy (OR (95% CI): 1.219 (0.766; 1.940), p=0.403). The same was also observed for the risk of stroke (1.273 (0.648; 2.501), p=0.483). After six months, persistence on dual antithrombotic therapy (33.4% patients) was higher than on triple therapy (10.3%, p&lt;0.001). Within the first three months, de-escalation from triple antithrombotic therapy to dual antithrombotic therapy (in 212 patients) was accompanied by a significant increase of bleeding requiring hospitalization (0% on dual vs. 3.3% on triple therapy, p=0.048). Conclusion Protective effect of dual antithrombotic therapy on the occurence of recurrent major adverse cardiovascular event is comparable to that of the triple antithrombotic therapy in non-selected patients with an acute coronary syndrome and atrial fibrillation. Moreover, long-term persistence on triple therapy is significantly lower due to bleeding risk. </jats:sec

P1727Prognosis predictors of patients with initial cardiogenic shock complicated acute myocardial infarction treated with primary angioplasty and intense antiplatelet therapy. PRAGUE-18 shock substudy

Abstract Background Early reperfusion of the infarct related artery is the only treatment improving prognosis of patients with initial cardiogenic shock (CGS) complicated acute myocardial infarction (AMI) (Killip class IV at admission). Purpose The analysis focused on subgroup of patients with initial CGS randomized into the multicenter PRAGUE-18 study (prasugrel vs. ticagrelor in primary PCI). Methods In the PRAGUE-18 study, patients with acute myocardial infarction (AMI) (n=1230) treated with primary percutaneous coronary intervention (pPCI) were immediately randomized to prasugrel or ticagrelor with intended treatment duration of 12 months. 53.6% (n=659) switched to clopidogrel after discharge. Major ischemic and bleeding events were followed throughout the entire study period. Beside standard laboratory tests, efficacy of ticagrelor and prasugrel was measured by flow cytometric VASP evaluation in patients selected for a laboratory sub-study (n=218). Acute heart failure (KILLIP &gt;1) was present in 11.8%, and 46 patients (3.7%) randomized to the study were in CGS. Results Patients with CGS were older [66.7 (48,3; 83,3) years] than those without CGS (KILLIP &lt;4), and had the highest prevalence of bundle brunch block on the initial ECG (RBBB in 6.5%, LBBB in 8.7%, p=0.003 for difference in bundle brunch blocks). Time delay to hospital admission [1,7 (0,4; 36,0) hs] was significantly shorter than in patients KILLIP &lt;4 [2,8 (0,8; 28,3hs; p=0.003]. Significantly more CGS patients had history of previous MI (19.6% vs 7.9%, p=0.011) and bypass graft surgery (6.5% vs 1.5%, p=0.041). 67.4% of CGS patients had multivessel disease and in 17.4% of these patients primary PCI was evaluated as suboptimal result or procedural failure (compared to 4.3% in patients without shock, p&lt;0.001). No difference was observed in clinical (primary and secondary endpoints, p=0.564) or laboratory efficacy between prasugrel and ticagrelor treated patients with CGS (p=0.800 for VASP index difference between prasugrel and ticagrelor 20±4 hs after loading doses). We did not find any difference in initial platelet activation (VASP index before P2Y12 inhibitors administration) in patients without acute heart failure (KILLIP I) [83.2 (54.1–94.2) %] and with KILLIP &gt; I [82.5 (65.7–96.9), p=0.999], and this was also confirmed for the difference between KILLIP I and KILLIP IV patients (p=0.416). Conclusion Results of the present analysis and defined predictors of mortality showed that prognosis of patients with initial cardiogenic complicated AMI treated with pPCI cannot be influenced by more potent platelet inhibition (than in AMI patients without CGS). Furthermore, the concluding evidence underscored adherence to the current guidelines' recommendation of the earliest possible reperfusion of infarct related artery as well as administration of prasugrel or ticagrelor. </jats:sec

Relationship between symptom-onset-to-balloon time and outcomes in patients with acute myocardial infarction treated with primary percutaneous coronary intervention

Abstract Background Time delay is an important prognostic factor and indicator of quality of care for patients with AMI indicated for primary percutaneous coronary intervention (PCI). Purpose Assessment of total ischaemia time and its relationship to catheterization findings and the incidence of ischaemic events within 1 year in patients treated with primary PCI. Method The analysis included 1230 patients with AIM and primary PCI randomized in the Prague-18 study (prasugrel vs. ticagrelor). We evaluated the total ischaemia time and two the intermediate intervals: A - from the symptom onset to the arrival to the hospital and B - from the entry the hospital to balloon time. We assessed the time delay in relation to patient characteristics, PCI results and ischaemic endpoints (death, reIM, stroke) within 30 days and 1 year. Results Median total ischaemia time was 3.2 hours. Its prolongation resulted in more frequent incidence of TIMI flow &amp;lt;2 before PCI (p=0.029), TIMI flow &amp;lt;3 after PCI (p=0.004) and suboptimal PCI (p=0.018). The interval A was significantly prolonged in women (p=0.001) and obese patients with BMI ≥30 kg / m2 (p=0.001). The interval B &amp;lt;30 min was achieved in 70% of patients, only 5.3% had interval &amp;gt;90 min. In 717 (61,6%) patients with increased risk (at least 1 criterion: age &amp;gt;70 years, STEMI anterior wall or LBBB, Killip II-IV, history of MI and CABG, SBP &amp;lt;100 mmHG and HR &amp;gt;100 / min), the prolongation of total ischaemia time (≤2 vs. 2.1–4 vs. 4.1–6 vs. &amp;gt;6 hours) resulted in a more frequent incidence of combined ischaemic endpoints within 1 year (p=0.034) and left ventricular systolic dysfunction (p=0.028). Conclusion The extension of total ischaemia time in patients treated with primary PCI resulted in a more frequent suboptimal result with TIMI flow &amp;lt;3. Female gender, older age and obesity in women were associated with an increase in total ischaemia time. In patients with increased risk, time delay resulted in a higher incidence of combined ischaemic endpoints within 1 year and left ventricular systolic dysfunction. Funding Acknowledgement Type of funding source: None </jats:sec

Clinical outcomes with drug-eluting stents, bare-metal stents, and bioresorbable scaffolds implanted in patients with AMI treated with primary PCI. Data from the Prague-18 trial

Abstract Background Drug-eluting stents (DESs) are the recommended choice of stents for primary PCI. Purpose/Methods The study aimed to determine why interventional cardiologists used non-DESs and how they had influenced the patient prognosis. The efficacy and safety outcomes of the different stents were also compared in treated with either prasugrel or ticagrelor. Results Of the PRAGUE 18 study patients, 749 (67.4%) were treated with DESs, 296 (26.6%) with BMS, and 66 (5.9%) with BVS. Cardiogenic shock at presentation and the left main disease, especially as culprit lesion, and right coronary artery stenosis were the reasons for BMS selection. The incidence of the primary net-clinical EP (CV death, nonfatal MI, stroke, major bleeding, or revascularization) at 7 days was 2.6% vs. 6.5%, and 3.0% in the DESs, BMSs, and BVSs, respectively (HR 2.7; 95% CI 1.419–5.15, P=0.002 for BMS vs. DES and 1.25 (0.29–5.39) for BVS vs. DES, P=0.76). Patients with BMSs were at higher risk of death at 30 days (HR 2.20; 95% CI 1.01–4.76; for BMS vs. DES, P=0.045), and at one year (HR 2.1; 95% CI 1.19–3.69; P=0.01); they also had higher composite of cardiac death, re-MI and stroke (HR 1.66; 95% CI 1.0–2.74; P=0.047) at one year. BMSs were associated with significantly higher rate of primary EPs either treated with prasugrel or ticagrelor. Conclusion Patients with the highest risk profile were preferably treated with BMS the contrary to BVS. BMSs were associated with a significantly higher rate of cardiovascular events either treated with prasugrel or ticagrelor. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Charles University Cardiovascular Research Program P-35 and Q-38, Charles University, Czech Republic </jats:sec

Interventional treatment in diabetics in the era of drugeluting stents and compliance to the ESC guidelines: Lessons learned from the Euro Heart Survey Programme

Aims: The objective of the study is to determine the demographics and the in-hospital outcome of diabetic and non-diabetic patients treated with percutaneous coronary interventions (PCI) in Europe, to report the type of equipment and technology used for PCI procedures in diabetics and to clarify whether the treatment of diabetic patients complies with current European Society of Cardiology (ESC) guidelines. Methods and results: A total of 14,458 patients treated with PCI were enrolled from 29 member countries of the ESC between June 2005 and January 2006. Data were collected on patient characteristics and treatment, using new Cardiology Audit and Registration Data standards. In total, 3,603 patients (24.9%) were diabetic. Diabetics were older, more often female and had a higher body mass index than non-diabetics. Diabetics had higher rates of hypercholesterolaemia and hypertension, while current smokers were more frequent in the non-diabetics. Diabetics also had significantly higher rates of previous cardiovascular events. Clopidogrel was administered only in 48.1% of diabetic patients before PCI, while IIb/IIIa inhibitors were 22.9% during PCI. At discharge, there was a major adjustment of treatment with increases in the use of Beta-blocker (80.4%), angiotensin converting enzyme inhibitor (ACEI, 71.3%) and statins (89.8%) compared with on admission (Beta-blocker 60.9%, ACEI 55.0%, statin 63.1%). Inhospital mortality was higher in diabetics (1.8% vs 1.2%) although the in-hospital MACCE rate was not significantly different (3.6% vs 3.0%, p=0.09). Conclusions: Diabetic patients treated with PCI were older with more comorbidity. According to ESC guideline, the under-usage of clopidogrel, GP IIb/IIIa inhibitors should be improved. PCI is now taken as a good opportunity to adjust the use of appropriate medication. © Europa Edition. All rights reserved

Dual antiplatelet therapy duration after coronary stenting in clinical practice: results of an EAPCI survey

Aims: Our aim was to report on a survey initiated by the EuropeanAssociation of Percutaneous Cardiovascular Interventions (EAPCI) concerning opinion on the evidence relating to dual antiplatelet therapy (DAPT) duration after coronary stenting.Methods and results: Results from three randomised clinical trials were scheduled to be presented at the American Heart Association Scientific Sessions 2014 (ARIA 2014). A web-based survey was distributed to all individuals registered in the EuroIntervention mailing list (n=15,200) both before and after ARIA 2014. A total of 1,134 physicians responded to the first (i.e., before AHA 2014) and 542 to the second (i.e., after ARIA 2014) survey. The majority of respondents interpreted trial results consistent with a substantial equipoise regarding the benefits and risks of an extended versus a standard DAPT strategy. Two respondents out of ten believed extended DAFT should be implemented in selected patients. After ARIA 2014, 46.1% of participants expressed uncertainty about the available evidence on DAFT duration, and 40.0% the need for clinical guidance.Conclusions: This EAPCI survey highlights considerable uncertainty within the medical community with regard to the optimal duration of DAFT after coronary stenting in the light of recent reported trial results. Updated recommendations for practising physicians to guide treatment decisions in routine clinical practice should be provided by international societies