Discussant to dr. Rutherford

Presentasjon om: "Discussant to dr. Rutherford"— Utskrift av presentasjonen:

1 Discussant to dr. Rutherford
Kjeld Falk Consultant

2 Thank you for at very interesting historical overview
The question you raises is a burning issue after the publication of the WOEST-study

3 Trippelbehandling Ingen liker å skrive ut pasienter etter stenting på trippel-behandling WOEST viser at vår magefølelse og ”kliniske erfaring” var riktig: svært høy blødningsrisiko Øker trippel-behandling versus dobbel-behandling dødelighet? I så fall bør vi slutte med trippelbehandling umiddelbart

4 Etter (kort) trippelbehandling: Hvilken dobbelbehandling?
Marevan + ASA? (WARIS-2, pre-stenting æra) Marevan + Plavix? (WOEST, stenting æra) NOAC + ASA? (kun anbefaling for Pradaxa, se tabell) Å unnlate DAPT (double antiplatelet therapy) i tidlig fase etter stenting har vært ansett for å være en kunstfeil Er det med moderne stenter nå tilstrekkelig med 1 platehemmer når det etter stenting samtidig er indikasjon for antikoagulasjon? Editorial i NEJM etter WOEST anfører at ”more studies are needed”

5 Tommelfingerregler NOAC: ikke godkjent sammen med de nye platehemmere (Brilique og Efient). Altså: Ikke nye+nye Trippelbehandling: 1. Nye platehemmere (Brilique og Efient) ikke godkjent, bare ASA og Plavix 2. NOAC: ikke som ledd i trippelbehandling (Pradaxa 110mg x2 i 1 måned er dog mulig, se tabell), men blødningsrisiko er meget høy og manglende mulighet for reversering/antidot gjør at mange mener man bør holde seg til Marevan ved trippelbehandling Altså: Trippelbehandling betyr ASA+Plavix+Marevan

6

7

8 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction
Developed in Collaboration with American College of Emergency Physicians and Society for Cardiovascular Angiography and Interventions © American College of Cardiology Foundation and American Heart Association, Inc.

9 Citation This slide set is adapted from the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction (Journal of the American College of Cardiology). Published on December 17, 2012, available at: [INSERT assigned url address (Please note: The URL of your article is always + the last half of your doi (j.jacc ) = ) The full-text guidelines are also available on the following Web sites: ACC ( and AHA (my.americanheart.org)

10 Complications After STEMI
Anticoagulation

11 Anticoagulation The following recommendations apply to patients who receive intracoronary stents during PCI for STEMI. Among individuals with STEMI who do not receive an intracoronary stent, the duration of DAPT beyond 14 days has not been studied adequately for patients who undergo balloon angioplasty alone, are treated with fibrinolysis alone, or do not receive reperfusion therapy. In this subset of patients with STEMI who do not receive an intracoronary stent, the threshold for initiation of oral anticoagulation for secondary prevention, either alone or in combination with aspirin, may be lower, especially if a shorter duration (i.e.,14 days) of DAPT is planned.

12 Anticoagulation I IIa IIb III
Anticoagulant therapy with a vitamin K antagonist should be provided to patients with STEMI and atrial fibrillation with CHADS2* score greater than or equal to 2, mechanical heart valves, venous thromboembolism, or hypercoagulable disorder. I IIa IIb III The duration of triple-antithrombotic therapy with a vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor should be minimized to the extent possible to limit the risk of bleeding.† *CHADS2 (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, previous Stroke/transient ischemic attack (doubled risk weight)) score. †Individual circumstances will vary and depend on the indications for triple therapy and the type of stent placed during PCI. After this initial treatment period, consider therapy with a vitamin K antagonist plus a single antiplatelet agent. For patients treated with fibrinolysis, consider triple therapy for 14 days, followed by a vitamin K antagonist plus a single antiplatelet agent.

13 Anticoagulation I IIa IIb III
Anticoagulant therapy with a vitamin K antagonist is reasonable for patients with STEMI and asymptomatic LV mural thrombi. I IIa IIb III Anticoagulant therapy may be considered for patients with STEMI and anterior-apical akinesis or dyskinesis. I IIa IIb III Targeting vitamin K antagonist therapy to a lower international normalized ratio (e.g., 2.0 to 2.5) might be considered in patients with STEMI who are receiving DAPT.

14 Konklusjon etter drøfting ved hjerteseksjonen 29.01.13
Vi følger inn til videre anbefalingene fra OUS som ligger på vår hjemmeside under tema platehemmere (Bendz/Eritsland) Ved blødningskomplikasjoner eller uakseptabel ”minor bleeding” på trippel-antitrombotisk behandling må videre antitrombotisk behandling avgjøres av kardiolog (consultant) Konferer!

15 Typisk hverdag for en ”consultant” ved hjerteseksjonen som skal svare på spørsmål om antitrombotisk behandling

16 ” I am a consultant. I am not here to do anything
” I am a consultant. I am not here to do anything. I am here to be consulted”. BMJ August 7, 2004, p.357