Problems and Solutions of Antiplatelet Therapy in Combination with Oral Anticoagulants Marvin H Eng, MD FSCAI FACC Assistant Professor of Medicine Division of Cardiology University of Texas Health Sciences Center San Antonio, Texas Disclosures • No relevant disclosures Outcomes Related to Severity of Bleeding Eikenbloom JW et al Circulation 2006;114:774-82 Non-Access Bleeding Ndereppa G et al Circ Cardiovasc Int 2013 ;6:354-351 HAS-BLED Predictive of Bleeding Hypertension Abn Renal/liver Stroke Bleeding history Labile INR Elderly Drug/ETOH Gallego P et al Circ Arrhythm Electrophysiol 2012;5:312-318 CHADS2 Estimation of stroke risk Stroke rate 20 Stroke rate per 100 patient-years Stroke rate 15 10 CHF HTN Age > 75 years DM Stroke or TIA 0 CHADS2 score Gage B et al JAMA 2001;285:2864-70 Risk for Recurrent Events Related to Thrombotic Milieu PASSION HORIZONS TYPHOON TRITON Stent Thrombosis DAPT-BMS era 30 Day Outcomes P=0.001 P=0.002 P=0.005 P=0.01 ASA ASA + Warfarin ASA + Ticlodipine 1° Endpoint TLR Angiographic Recurrent MI thrombus Leon MB et al NEJM 1998;339:1665-71 ASA+ Warfarin in ACS or MI Stratified by Bleeding/Thrombotic Risk Rothberg MB et al Annals of Internal Medicine 2005:143:241-250 Stent Characteristics Cypher Taxus Promus Endeavor Resolute Xience Platform Bx Velocity Express/Li Element berte Driver Integrity ML Vision Architecture Closed Open Open Mod.Open Cont-Open Open Alloy 316L 316L Platinum Cobalt Chromium Chromium Cobalt Chromium Cobalt Chromium Strut 140 μm 132μm/9 7μm 81 μm 91 μm 91 μm 81 μm Drug Sirolimus Paclitaxel Everolimus Zotarolimus Zotarolimus Everolimus Polymer PEVA/PMB SIBS A Translute VCF-HFP PC Biolinx VDF-HFP Kinetics 80% in 30d 10.2%10d 80% 30d 98% 14 d 85% 60d 80% 30d Elution Time 168 d Unknown 120 d 21-22 d 180 d 120 d Adapted from Eng MH and Kandzari DE E-ZES/EES Neointimal Coverage Kim SJ et al Coronary Artery Disease 2013; 24:431-439 DAPT Duration RESET- month DAPT in E-ZES Kim BK et al JACC 2012;60:1340-8 OPTIMIZE E-ZES 0-90 days P=NS 3.5 2.5 Mo DAPT 1.5 12 Mo DAPT 0.5 NACCE Major Bleeding Cardiac Death MACCE Stent Thrombosis Feres, F et al JAMA 2013;310:2510-2522 OPTIMIZE E-ZES 91d-1yr P=NS 3 Mo DAPT 12 Mo DAPT Feres, F et al JAMA 2013;310:2510-2522 E-ZES (ZEUS) ZES in non-ideal candidates YR ZES n=802 BMS n=804 HR Pvalue MACE TVR 17.5% 22.1% 0.76 (0.61-0.95) 0.011 5.9% 10.7% 0.53 (0.37-0.75)