September 25, 2020 PRESENTED BY: Joaquin E. CigarroaMD, Clinical Chief, KCVIDivision Head, CardiologyProfessor of Medicine, OHSU

ACS: 2020 Update: A Focus on Bleeding and Bleeding AvoidanceOHSU

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Conflict of Interest

• NoneOHSU

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Objectives

• Understand temporal trends during index hospitalization

• Risk stratification• Bleeding and ischemic risk• DAPT and duration• Special populations

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Temporal Trends of In-Hospital Complications of ACSStahli et al International Journal of Cardiology 2020

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Temporal Trends in Complications

Recurrent MI Bleeding

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Temporal Trends

Acute Renal Failure New-onset Atrial Fibrillation

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Bleeding Risk FactorsESC 2020 ACS Guidelines

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Bleeding Events Prior to AngiographyRedfors et al JACC 2016

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Bleeding and Management

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Clinical Case 1

• 72 year old woman with NSTEMI, permanent atrial fibrillation and elevated CHADSVASC score of 3 on a non-vitamin K antagonist develops exertional angina. A stress test is abnormal with high risk features. Coronary angiography demonstrates severe proximal LAD disease and she is treated with a drug eluting stent.

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Discharge MedicationsA. Aspirin 81 mg daily and P2Y12

inhibitorB. Warfarin and clopidogrel 75 mg dailyC. Rivaroxiban 15 mg daily plus

clopidogrel 75 mg daily D. Dabigatran 150 mg bid plus

clopidogrel 75 mg daily E. Apixaban 5 mg po bid plus clopidogrel

75 mg daily

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Dual vs Triple Tx in ACS Patients with indication for AC

Gupta et al ACC 2020

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Management of Antithrombotic Therapy in Atrial Fibrillation Patients Undergoing PCI

JACC State-of-the-Art Review Capodanno et al 109

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AFIRENEJM 2019

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Stent Thrombosis in Afib Patients: AugustusLopes et al Circulation

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Stent Thrombosis in Afib Patients: AugustusLopes et al Circulation

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Discharge MedicationsA. Aspirin 81 mg daily and P2Y12 inhibitorB. Warfarin and clopidogrel 75 mg dailyC. Rivaroxiban 15 mg daily plus clopidogrel

75 mg daily D. Dabigatran 150 mg bid plus clopidogrel

75 mg daily E. Apixaban 5 mg po bid plus clopidogrel 75

mg daily

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Atrial Fibrillation Recommendations

1. Double therapy is preferred to triple therapy to reduce hemorrhagic complications without a signal of harm with regards to stent thrombosis.

2. Non-vitamin K antagonists are preferred to warfarin and should be used at doses which are effective to reduce systemic thromboemboli.

3. Patients on double therapy all start on triple therapy for a period of at least periprocedurallyto one month.

4. Reasonable to stop antiplatelet tx at one year.

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ACS Post PCI

• 76 year old woman with hypertension, hyperlipidemia and Stage 3 CKD is admitted with NSTEMI and treated with DES to the proximal LADOHSU

Discharge Antiplatelets1. Aspirin 81 mg daily plus P2Y12 inhibitor

for 12 months2. Aspirin 81 mg daily plus P2Y12 inhibitor

for 30 months3. Aspirin 81 mg daily and Ticagrelor 90 mg

po bid for 3 month followed by Ticagrelor alone for 15 months

4. Aspirin 75-100 mg daily and ticagrelor 90 mg po bid for one month followed by Ticagrelor 90 mg bid for with 23 months

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Twilight ACSMehran AHA 2019

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Discharge Antiplatelets1. Aspirin 81 mg daily plus P2Y12 inhibitor

for 12 months2. Aspirin 81 mg daily plus P2Y12 inhibitor

for 30 months3. Aspirin 81 mg daily and Ticagrelor 90 mg

po bid for 3 month followed by Ticagrelor alone for 15 months

4. Aspirin 75-100 mg daily and ticagrelor 90 mg po bid for one month followed by Ticagrelor 90 mg bid for with 23 months

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Summary

1. Bleeding is a common occurrence and is associated with excess morbidity and mortality.

2. Antiplatelet therapy including DAPT is no longer a 12 month standard answer post ACS.

3. Double therapy in patients with Afib should include triple therapy for the first week to minimize stent thrombosis and maybe to one month. Double therapy should be the default and triple therapy should be avoided.

4. Abbreviated DAPT lowers bleeding without signal of excess risk of MACE

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Thank You!

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