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Optimizing treatment for ACS patient with 3 vessel disease & complete heart block Dinh Duc Huy, MD, FSCAI Nguyen Ngo Thanh Phuong, MD Tam Duc Heart Hospital HỘI NGHỊ KHOA HỌC TIM MẠCH

Optimizing treatment for ACS patient with 3 vessel disease

& complete heart block

Dinh Duc Huy, MD, FSCAI Nguyen Ngo Thanh Phuong, MD

Tam Duc Heart Hospital

HỘI NGHỊ KHOA HỌC TIM MẠCH TOÀN QUỐC 2015

• Chest pain sometimes

• Weakness and fatigue on exertion 5 days before

• Shortness of breath on admission day

On admission ECG

Monitoring ECG: BAV II intermittent BAV III

 Left: 50% stenosis &

diffuse stenosis after the bifurcation of the

popliteal artery

TREATMENT:

 TPM/PPM?

 Coronary angiogram? When?

 PCI/CABG before or after PPM?

 Anti-platelet therapy? (Pretreatment? Clopidogrel or New drugs [Pasugrel/Ticagrelor] to be combined

with Aspirin?) for how long?

1 The optimal timing of ticagrelor or clopidogrel for patients

scheduled for an invasive strategy has not been adequately

investigated, no recommendation for or against pretreatment

2 Based on the ACCOAST results, pretreatment with prasugrel is

not recommended (TIMI major bleeds were significantly

increased in the pretreatment group at 7 days

Bellemain-Appaix A et al BMJ 2014;349:g6269

Pretreatment in NSTE-ACS + PCI (RCTs)

TRANSLATE ACS Registry: 9251 ACS patients

Thienopyridine naive, undergoing PCI- Real life PCI

Effron MB et al J Am Coll Cardiol 2014;63(12_S)

Recommendations for management of new bundle branch block and atrio-ventricular conduction disorders in ACS

Euro Intervention 2014

 Prompt opening of the infarct vessel is often sufficient to

reverse new-onset ischaemic conduction disturbances This is

especially true for atrioventricular (AV) block in the setting of inferior infarctions

 Temporary pacing is indicated for symptomatic

life-threatening bradycardia not resolving after successful

reperfusion and after medical treatment in the presence of

high-degree AV block and intraventricular conduction defects

 Permanent pacing is considered for disturbances that persist

beyond the acute phase after the myocardial infarction

Case management

•TPM

•TVD- SYNTAX score 22

CABG or PCI For revascularization?

Tỷ lệ biến cố tim mạch nặng theo điểm số SYNTAX score

NEJM 2009; 360: 961-72

CABGvs PCI for

patients with

three-vessel disease: final 5-year follow up

of the SYNTAX trial

European Heart Journal

paclitaxel-eluting DES

suggest that

CABG should remain the standard of care

Our patient treatment- 3 VD PCI with DES

• TPM (+)

• DES in RCA, LCx, LAD

• Good result post PCI

• All TIMI 3 flow

• Normal sinus rhythm

3 days after PCI

Antiplatelet therapy for ACS patient

1 Which is the best option of antiplatelet

therapy for ACS patient undergoing PCI?

2 Should we do pre-treatment? (perhaps NO)

3 Can we give Ticagrelor for patient with

complete heart block?

4 How long should we prolong DAPT?

CURE NEJM 2001;345:494-502 Fox et al Circulation 2004;110:1202-1208,

CURE study- Corner stone for DAPT in ACS:

Clopidogrel+ ASA are better than ASA alone

Placebo (11.4%)

Wiviott et al New Eng J Med 2007; 357 No benefit with prior stroke, age > 75, weight < 60kg

• Multicenter, double-blind, randomized trial

• 18,624 ACS patients

• Ticagrelor (180-mg loading dose, 90 mg twice daily

thereafter) and clopidogrel (300-to-600-mg loadingdose,

75 mg daily thereafter)

Wallentin L et al N Engl J Med 2009;361

0 2 4 6 8 10 12 14 16

1 Lindholm D, et al J Am Coll Cardiol 2013;61(suppl 10):Abstract 901–903

2 Wallentin L et al N Engl J Med 2009;361:1045–1057

HR: 1.07 (95% CI 0.95–1.19

PLATO- Bradycardia Events

Wallentin L et al N Engl J Med 2009;361

 Holter monitoring during the first week in 2866 patients

 Repeated at 30 days in 1991 patients

 Higher incidence of ventricular pauses in the 1st week, but not

at day 30; pauses were rarely associated with symptoms

 No significant difference to the incidence of syncope or

pacemaker implantation

Methods

7-day cECG recording initiated at the time of randomisation, which was within 24 h of symptom onset, and then repeated at 1 month after randomization during the convalescent phase

The principal safety endpoint was the incidence of ventricular

pauses lasting at least 3 seconds

J Am Coll Cardiol 2011;57:1908–16

cECG Assessment Patient CONSORT Diagram

Arrhythmias at Visit 1 (Week 1) and Visit 2 (Day 30) for All Patients

 More ventricular pauses ≥3 s in patients assigned to ticagrelor

during the first week (5.8% vs 3.6%; p=0.006)

 At 1 month, pauses ≥3 s were less and similar between treatments

(2.1% vs 1.7%)

J Am Coll Cardiol 2011;57:1908–16

J Am Coll Cardiol 2011;57:1908–16

• Week 1: 70 patients

(3.2% ) had 1 pause, 20 (0.6%) had > 4 pauses

• 1 month: 9 patients

(0.05%) had 1 pause, 17 (0.8%) had > 4 pauses

Study conclusions

1 More patients treated with ticagrelor compared

with clopidogrel had ventricular pauses, which were

predominantly asymptomatic, sinoatrial nodal in

origin, and nocturnal and occurred most frequently

in the acute phase of ACS

2 There were no differences between ticagrelor and

clopidogrel in the incidence of clinically reported

bradycardic adverse events, including syncope,

pacemaker placement, and cardiac arrest

J Am Coll Cardiol 2011;57:1908–16

Our patient treatment

2 Low dose beta blocker started during follow up

3 Well, so far, 3 months after the index event, no chest pain, no sign and symptoms of HF; ECG maintains normal sinus rhythm

DAPT for how long?

A 1-year durationof DAPT with clopidogrel was associated with a 26.9% RRR of death, MI or stroke (8.6% vs 11.8%; 95% CI 3.9,

44.4; P= 0.02) vs 1-month DAPT in CREDO trial

Stronger antiplatelet therapy beyond 1 year in

prior MI or angiographic-proven CAD

European Heart Journal doi:10.1093/eurheartj/ehv377 (August 2015)

Conclusions

1 Early invasive strategy for high risk ACS

2 Revascularisation is often sufficient to reverse

new-onset ischaemic conduction disturbances

3 No clear benefit of pretreatment antiplatelet therapy

4 Treatment with ticagrelor (vs clopidogrel) significantly

reduced the rate MACCE without increasing the overall major bleeding or bradycardic adverse events

5 DAPT for 12 months after ACS Need careful assessment

of the ischaemic and bleeding risks if plan to prolong

DAPT duration

Thank you for your attention!