Embed Size (px)
Citation preview
www.metcardio.org
Applications of bivalirudin in Applications of bivalirudin in interventional cardiologyinterventional cardiology
Giuseppe Biondi ZoccaiGiuseppe Biondi ZoccaiDivisione di CardiologiaDivisione di Cardiologia
Università di TorinoUniversità di TorinoOspedale S. Giovanni Battista di TorinoOspedale S. Giovanni Battista di Torino
[email protected]@gmail.com
www.metcardio.org
LEARNING GOALS• SCOPE OF THE PROBLEM• TREATMENT ALTERNATIVES• POTENTIAL CLINICAL USES
– Heparin-induced thrombocytopenia– Ischemic cardiomyopathy– Chronic stable angina– Non-ST-elevation acute coronary syndromes– ST-elevation acute coronary syndromes– Transcatheter aortic valve implantation
www.metcardio.org
SCOPE OF THE PROBLEMImpact of MI and major bleeding in the first
30 days on 1-year mortality in ACUITY
Major Bleed only (without MI) (N=551) 12.5%28.9%Both MI and Major Bleed (N=94)
3.4%No MI or Major Bleed (N=12,557)
MI only (without Major Bleed) (N=611) 8.6%
www.metcardio.org
LEARNING GOALS• SCOPE OF THE PROBLEM• TREATMENT ALTERNATIVES• POTENTIAL CLINICAL USES
– Heparin-induced thrombocytopenia– Ischemic cardiomyopathy– Chronic stable angina– Non-ST-elevation acute coronary syndromes– ST-elevation acute coronary syndromes– Transcatheter aortic valve implantation
www.metcardio.org
TREATMENT ALTERNATIVES
Tissue factor
Plasma clottingcascade
Prothrombin
Thrombin
Fibrinogen Fibrin
Thrombus
Platelet aggregation
Conformational activation of GPIIb/IIIa
Collagen
Thromboxane A2
ADP
AT
AT
Aspirin
ClopidogrelPrasugrelTicagrelor
GPIIb/IIIainhibitors
FactorXa
BivalirudinHirudin
Argatroban
LMWHHeparin
Thrombo-lytics
Coagulationcascade
Coagulationcascade
PlateletcascadePlateletcascade
www.metcardio.org
TREATMENT ALTERNATIVES
Bleeding RiskBleeding Risk
Ischemic RiskIschemic Risk
Renal functionRenal functionAgeAge
Time to CathTime to Cath
CostCost
Ease of useEase of use
PCI vs CABG vs Med RxPCI vs CABG vs Med Rx
Low: Enox, Bival, UFHMod: Enox, Bival, UFHHigh: Enox, Fonda, Bival
Low: Enox, Bival, UFHMod: Enox, Bival, UFHHigh: Enox, Fonda, Bival
Low: Enox, UFH, BivalMod: Bival, Fonda, UFHHigh: Bival, Fonda, UFH
Low: Enox, UFH, BivalMod: Bival, Fonda, UFHHigh: Bival, Fonda, UFH
Elderly: ??? Elderly: ???
Normal: Enox, Bival, Fonda, UFHCKD: Bival, UFH Normal: Enox, Bival, Fonda, UFHCKD: Bival, UFH
Enox, UFHFonda, Bival?Enox, UFHFonda, Bival?
Enox, Bival, Fonda Enox, Bival, Fonda
Rapid: Bival, UFHEarly: Enox, UFH, BivalDelayed: Enox
Rapid: Bival, UFHEarly: Enox, UFH, BivalDelayed: Enox
PCI: Enox, Bival, UFHCABG: UFHMed Rx: Enox, Fonda, Bival
PCI: Enox, Bival, UFHCABG: UFHMed Rx: Enox, Fonda, Bival
www.metcardio.org
LEARNING GOALS• SCOPE OF THE PROBLEM• TREATMENT ALTERNATIVES• POTENTIAL CLINICAL USES
– Heparin-induced thrombocytopenia– Ischemic cardiomyopathy– Chronic stable angina– Non-ST-elevation acute coronary syndromes– ST-elevation acute coronary syndromes– Transcatheter aortic valve implantation
www.metcardio.org
47-YEAR-OLD WOMAN WITH UNSTABLE ANGINA AND HIT
What is the most appropriate antithrombotic What is the most appropriate antithrombotic regimen for PCI in patients with HIT?regimen for PCI in patients with HIT?
www.metcardio.org
HEPARIN-INDUCED THROMBOCYTOPENIA
The Anticoagulant Therapy with Bivalirudin to Assist in the performance of PCI in patients with heparin-
induced Thrombocytopenia (ATBAT) trial
www.metcardio.org
LEARNING GOALS• SCOPE OF THE PROBLEM• TREATMENT ALTERNATIVES• POTENTIAL CLINICAL USES
– Heparin-induced thrombocytopenia– Ischemic cardiomyopathy– Chronic stable angina– Non-ST-elevation acute coronary syndromes– ST-elevation acute coronary syndromes– Transcatheter aortic valve implantation
www.metcardio.org
69-YEAR-OLD MAN WITH CSA, SEVERE LVD, PRIOR CABG AND PRIOR STROKE
What is the most appropriate antithrombotic What is the most appropriate antithrombotic regimen for ischemic cardiomyopathy or CSA?regimen for ischemic cardiomyopathy or CSA?
www.metcardio.org
ISCHEMIC CARDIOMYOPATHY OR CHRONIC STABLE ANGINA
Kastrati et al, New Engl J Med 2008
www.metcardio.org
ISCHEMIC CARDIOMYOPATHY OR CHRONIC STABLE ANGINA
Kastrati et al, New Engl J Med 2008
www.metcardio.org
LEARNING GOALS• SCOPE OF THE PROBLEM• TREATMENT ALTERNATIVES• POTENTIAL CLINICAL USES
– Heparin-induced thrombocytopenia– Ischemic cardiomyopathy– Chronic stable angina– Non-ST-elevation acute coronary syndromes– ST-elevation acute coronary syndromes– Transcatheter aortic valve implantation
www.metcardio.org
71-YEAR-OLD WOMAN WITH NSTEMI AND CHRONIC RENAL FAILURE
What is the most appropriate What is the most appropriate antithrombotic regimen for NSTEACS?antithrombotic regimen for NSTEACS?
www.metcardio.org
NSTEACS1-month rate of major adverse cardiac
events in the ACUITY trial
www.metcardio.org
NSTEACS1-month rate of net clinical adverse
events in the ACUITY trial
www.metcardio.org
LEARNING GOALS• SCOPE OF THE PROBLEM• TREATMENT ALTERNATIVES• POTENTIAL CLINICAL USES
– Heparin-induced thrombocytopenia– Ischemic cardiomyopathy– Chronic stable angina– Non-ST-elevation acute coronary syndromes– ST-elevation acute coronary syndromes– Transcatheter aortic valve implantation
www.metcardio.org
76-YEAR-OLD WOMAN WITH ST-ELEVATION ACS AND CARDIOGENIC SHOCK
What is the most appropriate What is the most appropriate antithrombotic regimen for STEMI?antithrombotic regimen for STEMI?
www.metcardio.org
ST-ELEVATION ACS
Mehran et al, Lancet 2009
www.metcardio.org
ST-ELEVATION ACS
Mehran et al, Lancet 2009
www.metcardio.org
ST-ELEVATION ACS
Mehran et al, Lancet 2009
www.metcardio.org
LEARNING GOALS• SCOPE OF THE PROBLEM• TREATMENT ALTERNATIVES• POTENTIAL CLINICAL USES
– Heparin-induced thrombocytopenia– Ischemic cardiomyopathy– Chronic stable angina– Non-ST-elevation acute coronary syndromes– ST-elevation acute coronary syndromes– Transcatheter aortic valve implantation
www.metcardio.org
87-YEAR-OLD MAN WITH SEVERE AORTIC STENOSIS AND PROHIBITIVE STS SCORE
What is the most appropriate What is the most appropriate antithrombotic regimen during TAVI?antithrombotic regimen during TAVI?
www.metcardio.org
TAKE HOME MESSAGES• The interventional cardiologist is challenged
every day by the quest for an optimal balance between preventing bleeding and thrombosis
• Several alternative parenteral antithrombotic drugs are available, with a significantly different efficacy and safety profile
• Bivalirudin may represent an effective and safe alternative in several clinical settings, especially when there is moderate or high risk for bleeding
www.metcardio.org
Thank you for your attention
For any correspondence: [email protected]
For these and further slides on these topics feel free to visit the metcardio.org website:
http://www.metcardio.org/slides.html
