An Academic Research Organization of Brigham and Women’s Hospital and Harvard Medical School... • Ticagrelor tăng nguy cơ chảy máu nặng theo TIMI nhưng không tăng chảy máu gây chết
Trang 1PGS TS Trương Quang Bình, FSCAI
Trang 2Các khuyến cáo về thời gian dùng thuốc
ức chế P2Y 12 sau hội chứng mạch vành cấp
Society Management Recommended Duration
Medical Ideally up to 12 months
PCI (DES) At least 12 months
Medical 12 months PCI 12 months
(After 12 mos, recommend single antiplatelet therapy over continuation of DAPT)
2014 ACCF/AHA UA/NSTEMI; 2013 ACCF/AHA STEMI; 2011 ESC NSTEACS; 2012 ESC STEMI;
ACCP
2
Trang 3Mauri et al NEJM 2014
DOI:10.1056/NEJMoa1409312
Trang 4DAPT: Tiếp tục hoặc ngưng thienopyridine
sau 12 tháng dùng/Stent ĐMV
Chết, NMCT hoặc đột quị
Trang 5Tiếp tục thienopyridine vs placebo ở bệnh nhân có hoặc không có HCVC
All DES and BMS randomized patients
Trang 6BN ổn định có t/s NMCT 1-3 năm trước + 1 YTNC huyết khối xơ vữa*
* Tuổi >65, ĐTĐ, NMCT lần 2, bệnh MV nhiều nhánh, hoặc
bệnh thận mạn không g/đ cuối
TNLS dựa vào số biến cố
Ticagrelor
60 mg x 2/ngày
Thiết kế nghiên cứu
ACC 2015
Trang 7An Academic Research Organization of
Brigham and Women’s Hospital and Harvard Medical School
Phân ngẫu nhiên 21,162 bệnh nhân
Ticagrelor
90 mg bid (N=7050)
Placebo (N=7067)
Ticagrelor
60 mg bid (N=7045)
Theo dõi
Theo dõi trung vị 33 tháng Min 16 tháng, max 47 tháng
ACC 2015
Trang 8Tháng kể từ khi phân nhóm ngẫu nhiên
Tiêu chí đánh giá chính: chết do nguyên nhân tim
mạch, NMCT hoặc đột quị
ACC 2015
Trang 9An Academic Research Organization of
Brigham and Women’s Hospital and Harvard Medical School
Trang 10Tóm tắt
• Thêm ticagrelor vào trên nền aspirin liều thấp
ở bệnh nhân có tiền sử NMCT làm giảm nguy
cơ chết do NN tim mạch, NMCT, đột quị
• Ticagrelor tăng nguy cơ chảy máu nặng theo
TIMI nhưng không tăng chảy máu gây chết
hoặc chảy máu nội sọ
=> Một số đối tượng hưởng lợi khi dùng DAPT kéo dài đến 3 năm
Trang 11An Academic Research Organization of
Brigham and Women’s Hospital and Harvard Medical School
2016 - DAPT SCORE
• Lợi ích/ nguy cơ ≥
2 điểm nên kéo dài DAPT trên 12
tháng
• Lợi ích/ nguy cơ <
2 không nên kéo dài DAPT trên 12 tháng
Trang 12Efficacy and Safety of Ticagrelor as Long-Term Secondary Prevention in Patients with Peripheral Artery Disease and Prior Myocardial Infarction
Marc P Bonaca, MD, MPH
on behalf of the PEGASUS-TIMI 54 Executive &
Steering Committees and Investigators
Trang 13Hypotheses
An Academic Research Organization of
Brigham and Women’s Hospital and Harvard Medical School
Patients with PAD and prior MI:
1 Would be at heightened risk for both MACE and
MALE relative to patients without PAD
2 Would derive a particularly robust reduction in
MACE risk with ticagrelor vs placebo
3 Would derive benefit for MALE with ticagrelor
vs placebo
Trang 14Methods
1 PAD was identified by sites at baseline as evidenced by one or
more of the following characteristics:
Ankle brachial index (ABI) ≤ 0.90, Prior peripheral revascularization, Claudication
prospectively collected and formally adjudicated Peripheral revascularizations were site reported.
composite of acute limb ischemia (ALI) or peripheral
revascularization for limb ischemia
PAD were adjusted for baseline differences
Trang 15Baseline Characteristics by PAD
No PAD N=20,017
PAD N=1,143
Risk Factors
An Academic Research Organization of
Brigham and Women’s Hospital and Harvard Medical School All p-values < 0.001 except gender (p=0.17)
Background ASA >99%, statin>93%, beta blocker 83% no significant
difference by baseline PAD
Trang 160 5%
Patients without
PAD N=6663 8.4%
Trang 17No PAD HR 0.86
95% (CI 0.77 –
0.96)
P-interaction 0.41
Placebo Ticagrelor (pooled doses)
ARR 1.0% NNT 100
MACE with Ticagrelor by PAD at Baseline
An Academic Research Organization of
Brigham and Women’s Hospital and Harvard Medical School Days from Randomization
Trang 180.46% 0.4%
HR 0.65 95% CI (0.44 – 0.95)
Trang 19Summary
An Academic Research Organization of
Brigham and Women’s Hospital and Harvard Medical School
Patients with prior MI and concomitant PAD
– Are at heightened risk of ischemic vascular
complications and mortality even after adjusting for
comorbidities
– Ticagrelor added to aspirin reduced MACE with a robust
ARR (>4%) & NNT (25) at 3 years
– Ticagrelor added to aspirin reduced limb ischemic events
Trang 20Conclusions
• Patients with PAD and prior MI are at heightened
risk of ischemic cardiovascular and limb events and derive a robust risk reduction from long-
term secondary prevention with ticagrelor
• The ongoing EUCLID trial will evaluate the
efficacy of ticagrelor vs clopidogrel
monotherapy in patients with PAD for major
adverse cardiovascular and limb events
Trang 21Chân thành cảm ơn quý vị