Mastering Complexity And Antiplatelet Therapy For Acs Patients

Striking the Balance: Era of Equipoise

Mastering complex PCI in HBR ACS patients

Antiplatelet Therapy strategies for HBR ACS patients

Getting Practical, how do I do It?

Acute coronary syndrome (ACS), a major cause of mortality, is often treated with percutaneous coronary intervention (PCI) alongside antiplatelet therapy to minimize thrombosis risk while balancing bleeding complications. Tailoring antiplatelet regimens to individual risk profiles is an emerging strategy to optimize treatment safety and effectiveness. The CardioSummit 2024, hosted by Sanofi in partnership with the Vietnam Heart Association and Terumo, focuses on enhancing cardiologists’ expertise in managing complex ACS-PCI cases and selecting the best antiplatelet therapy, especially for those at increased bleeding risk.

Key features of the program include:

Recent advancement in antiplatelet therapy for high-bleeding-risk patients along patient ‘s journey.

Strategies for complex coronary interventions, addressing challenges in the management of leftmain disease, bifurcation, multi-vessel disease, etc.

The symposium features interactive sessions led by a distinguished panel of experts renowned in the international and Southeast Asian cardiologist community:

Prof. Mamas A. Mamas (Keele University, UK):  Associate Editor of Circulation Cardiovascular Interventions and a member of the E-Cardiology working group of the European Society of Cardiology.

Prof. Dirk Sibbing (Ludwig-Maximilians University, Munich, Germany): Active task force member: ESC 2020 guidelines on NSTE-ACS, ESC 2018 guidelines on myocardial revascularization.

Prof. Davide Capodanno (University of Catania, Catania, Italy): Co-Director of the PCR Clinical Research Course and Associate Director of TCT; Editor-in-Chief of Eurointervention.

Event date: August 24th, 2024

Session 1: Striking the Balance: Era of Equipoise

• Significant advancements have been made in optimizing intra- and post-procedural pharmacological management in interventional cardiology.¹
• The incidence of major bleeding among patients with acute coronary syndrome (ACS) remains considerable; increased bleeding correlates with higher mortality rates. ² 
• Individualized clinical judgment is crucial, considering patient comorbidities, coronary anatomy, and the characteristics of different antithrombotic strategies.¹
• The East Asian Paradox highlights that, despite higher on-treatment platelet reactivity with clopidogrel in East Asian populations compared to Western populations, there are lower rates of ischemic events (including stent thrombosis) and higher rates of bleeding. This underscores the need for customized antiplatelet therapy for East Asian patients.^3-4
• Clopidogrel may be the preferred P2Y12 inhibitor for older patients, particularly those at increased risk of bleeding.⁵

Session 2: Mastering complex PCI in HBR ACS patients.

Managing complex PCI requires personalized treatment strategies and advanced technologies to balance ischemic and bleeding risks, especially in high-risk patients.

• Complex PCI involves multivessel disease, chronic total occlusion (CTO), bifurcation PCI (≥2 stents), calcified lesions, and left main disease. It is influenced by patient factors like age, frailty, sex, and co-morbidities (e.g., high bleeding risk).
• Patient Factors include
  • Age: Older patients fare worse.
    Frailty: Leads to higher mortality and longer hospital stays.
  • Sex: Women have poorer outcomes compared to men.
  • Co-morbidities: High bleeding risk complicates treatment.
• Lesion Characteristics: Complex lesions include CTOs, bifurcations, and calcifications. The SYNTAX score helps guide treatment decisions between PCI and surgery.
• Technological Tools: IVUS, OCT, rotational atherectomy, and stents like Ultimaster NagomiTM improve outcomes, especially in complex lesions.
• Master-DAPT Trial Findings:
  • Compared abbreviated DAPT with standard DAPT in high-bleeding risk patients.
  • Abbreviated DAPT: Non-inferior for ischemic events, superior in reducing bleeding.

Session 3: Antiplatelet Therapy strategies for HBR ACS patients

• To mitigate bleeding risk, for HBR patients, 1–3-month DAPT should be considered.^5-9
• An unguided de-escalation strategy using clopidogrel, compared to a ticagrelor-based DAPT approach, has shown benefits in reducing the incidence of net adverse clinical events (NACE), regardless of the ischemic or bleeding risk.^10-12
• In indirect comparison, de-escalation reduced the risk for NACE, while short DAPT decreased major bleeding.¹³
• Considering the East Asian Paradox, switching from ticagrelor to clopidogrel after one month seems suitable for Asian patients.¹⁴
• For the long-term prevention of ischemic events in post-ACS PCI patients, aspirin remains the default strategy; however, emerging evidence suggests that P2Y12 inhibitors, particularly clopidogrel, may offer a net clinical benefit over aspirin in the long-term treatment phase.^{5, 15-17}

Session 4: Getting Practical, how do I do It?

Left main PCI
Base Left Main Stenosis (LMS) PCI decisions on imaging, and tailor stent selection and antiplatelet therapy to patient needs.

• Revascularization: Use iFR-based testing to assess LMS lesions for treatment.
• Guidelines & Imaging: Follow ESC guidelines; intravascular imaging (IVUS/OCT) is mandatory for LMS cases to evaluate lesion significance and calcium.
• Stenting Strategy: Use a single-stent for simple cases; two-stent for complex bifurcations based on anatomy.
• Stent Design: The Ultimaster NagomiTM stent offers better coverage for large bifurcations.
• Antiplatelet Therapy: The MASTER DAPT trial supports customizing therapy for high bleeding risk patients.
   

Multivessel PCI

• Consider pitfalls related to contrast usage, radiation management, and choosing between stents and drug-eluting balloons for diffuse disease.
• It’s important to adhere to established guidelines for optimal patient outcomes. 
• Hybrid coronary revascularization (HCR) has lower rates of all-cause mortality and myocardial infarction than traditional CABG, indicating it may be a viable option for multivessel disease patients.
• The recommendations for a practical approach to multivessel PCI emphasize the importance of careful patient selection based on individual risk factors and disease characteristics.

Ref:
1.    Cao D, et al. Eur Heart J. 2021 Jan 21;42(4):339-351
2.    Moscucci M, et al. Eur Heart J. 2003 Oct;24(20):1815-23
3.    Kang J, Kim HS. Korean Circ J. 2018 Jul;48(7):537-551
4.    Jeong YH, et al. J Cardiovasc Interv. 2024 Jul;3(3):119-135
5.    Byrne RA, et al. Eur Heart J. 2023 Oct 12;44(38):3720-3826
6.    Kim BK, et al. JAMA. 2020;323:2407-2416 
7.    Watanabe H, et al. JAMA Cardiol. 2022;7:407-417 
8.    Hong SJ, et al. Circulation. 2024;149:562–573
9.    Ge Z, et al. Lancet. 2024;403:1866-1878
10.    Kim CJ, et al. Lancet. 2021;398:1305-1316
11.    Kim MC, et al. EuroIntervention. 2023;19:e832-e843
12.    Lee M, et al. JAMA Cardiol. 2024;9:125-133
13.    Laudani C, Capodanno D, et al. JACC Cardiovasc Interv. 2022;15:268-277
14.    Gorog DA, et al. Thromb Haemost 2023;123(8):773–792
15.    Kim HS, et al. Lancet. 2021 Jun 26;397(10293):2487-2496
16.    Kang J, et al. Circulation. 2023 Jan 10;147(2):108-117
17.    Gragnano F, et al. J Am Coll Cardiol. 2023 Jul 11;82(2):89-105