Xử trí rung nhĩ mới xuất hiện ở bệnh nhân, hội chứng vành cấp

Case presentation
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79 years- old lady
BMI 22
Hypertension
Dyslipidemia
PCI (DES LAD Jan. 2015)
High risk UA- TIMI 5
HR 70
BP 120/55
RR 18
T 36.80C
SpO2 98% (room air)

• On regular Rx:
–
–
–
–
–
–
–

–
–

Losartan 50mg qd
Amlodipin 5mg qd
ASA 81mg qd
Ticagrelor 90 bid
Metoprolol succinate 25mg
qd
ISMN 60mg qd
Furosemide/ Spironolactone
10/25mg qd
Rosuvastatin 20mg qd
Trimetazidine 35mg bid


Blood investigations
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WBC 10 k/uL (N: 52%)
PLT 242 K/uL
Hs-CRP 0.8 mg/L
HGB 12 g/dL

Creatinin 92 mmol/l
eGFR 39ml/ph/1.73m2
AST 28 ALT 26 U/L
TSH 2.5 mUI/L

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Cholesterol
HDL-C
LDL-C
TG

• NT-proBNP
• Hs-TnT

3.5
1.1
2.2
2.5 mmol/L
364pg/ml
14 – 13 pg/ml


On admission ECG

Sinus rhythm 85 bpm, normal QRS axis and PR interval
ST-T depression 1-2 mm in DI, DII, V1-V4

Imaging findings
Echocardiography
• LVEF 65%
• No chamber dilatation
• No RWMA; No thrombus
• MR (+) TR (+)
• S PAP 25mmHg
• TAPSE 20

HIGH RISK UNSTABLE ANGINA (TIMI SCORE 5)
HYPERTENSION – DYSLIPIDEMIA – CHRONIC KIDNEY DISEASE

Plan for early invasive strategy


Coronary angiogram
1. Patent LAD stent. No ISR
2. Diffused LCx (small vessel)
3. Total occlusion RCA
For RCA CTO intervention


RCA PCI

• Complex PCI with 3 overlapping DES implantation
(2.5x21mm, 2.75x38mm, 3x38mm)
• TIMI 3 flow of RCA post stenting

Post PCI- CCU f/u
Day 1-2
• Felt better
• No chest pain
• Hemodynamic stability
• HR: 100- 70bpm
• BP: 110/50mmHg

Day 3
• Palpitation
• Monitor: paroxysmal
fast AF (110-120 bpm)
• BP: 110/50 mmHg
• SpO2 96%
Echo: LVEF 50%
• CHA2DS2-VASc : 5
• HAS-BLED: 3


Anti-thrombotic therapy for ACS/PCI plus AF
AF
Anticoagulant Rx

• Essential to
prevent thromboembolic events
• Superior to
single or dual
antiplatelet
therapy

• Life long

ACS/PCI
DAPT Rx
• Superior to
ASA alone in
ACS
• Essential to
prevent stent
thrombosis
post PCI
• ≥12 months
Lip et al. Eur Heart J 2014;35:3155-3179

AF and
ACS/PCI
Triple Rx
• By what
medications?
• For how long?
• How much
data do we
have?


Highest bleeding rate with triple therapy
Danish cohort of 82854 patients with AF followed for an average of 3.3 years

Significant bleeding rate with triple therapy was 15.7 per 100 patient-year

Hansen et al. Arch Intern Med 2010;170:1433-1441


Risk of stroke according to CHA2DS2-VASc
CHA2DS2-VASc criteria

Score

Congestive heart failure/
left ventricular dysfunction

1

Hypertension

1

Age 75 years

2

Diabetes mellitus

1

Stroke/transient ischaemic
attack/TE

2

Vascular disease (prior myocardial
infarction, peripheral artery
disease, or aortic plaque)

1

Age 65–74 years

1

Sex category (i.e. female gender)

1

Total
score

N

Adjusted
stroke rate
(%/year)*

0

1

0.0

1

422

1.3

2

1230

2.2

3

1730

3.2

4

1718

4.0

5

1159

6.7

6

679

9.8

7

294

9.6

8

82

6.7

9

14

15.2

*Adjusted for warfarin use. Theoretical rates without
therapy; assuming that warfarin provides a 64%
reduction in stroke risk, based on Hart RG et al. 2007.

TE = thromboembolism
Lip G et al. Chest 2010;137:263–72; Lip G et al. Stroke 2010;41:2731–8;
ESC guidelines: Camm J et al. Eur Heart J 2010;31:2369–429; Hart RG et al. Ann Intern Med 2007;146:857–67

Risk of bleeding according to HAS-BLED
HAS-BLED risk criteria

Hypertension

(SBP >160 mmHg)

Abnormal renal or liver
function (1 point each)

Score
1
1 or 2

HAS-BLED
total score

N

Number Bleeds per 100
of bleeds patient-years*

0

798

9

1.13

1

1286

13

1.02

2

744

14

1.88

Stroke

1

3

187

7

3.74

Bleeding

1

4

46

4

8.70

5

8

1

12.5

6

2

0

0.0

7

0

–

–

8

0

–

–

9

0

–

–

(history or predisposition)

Labile INRs

1

Elderly

1

(e.g. age >65 years)

Drugs† or alcohol
(1 point each)

1 or 2

Pisters R et al. Chest 2010;138:1093–100; ESC guidelines: Camm J et al. Eur Heart J 2010;31:2369–429


Triple versus dual anti-thrombotic
therapy in AF- ACS/PCI
Available Data
Large RCT

Smaller RCT

Prospecitve Retrospective
cohort
cohort

Meta-analysis

None

WOEST

eg,

AVIATOR

CHEN et al.
Herz 2015

ISAR
TRIPLE

eg, DANISH
(crude and
adjusted)

GAO et al. Clin
Cardiol 2015


Methods Open-label, multi-centre, randomised, controlled trial in 15 centers
in Belgium and the Netherlands
 Clopidogrel alone (double therapy) or clopidogrel plus aspirin
(triple therapy)
 The primary outcome was any bleeding within 1 year of PCI
Lancet 2013; 381: 1107–15


WOEST study
Primary endpoint :
Total number of bleeding
events (TIMI)

Lancet 2013; 381: 1107–15

WOEST-Secondary and safety endpoints at 1 year
Lower mortality rate in double versus triple therapy

Lancet 2013; 381: 1107–15


OBJECTIVES …Whether shortening the duration of clopidogrel
therapy from 6 months to 6 weeks after DES implantation was
associated with a superior net clinical outcome in patients receiving
concomitant aspirin and OAC.
METHODS… Randomized, open-label trial. 614 patients receiving 6week clopidogrel therapy (n= 307) or 6-month clopidogrel therapy (n=
307). The primary endpoint was a composite of death, MI,

definite ST, stroke, or TIMI major bleeding at 9 months.
J Am Coll Cardiol 2015;65:1619–29


Main findings from
ISAR- TRIPLE
(A)primary endpoint
(cumulative incidence of
death, myocardial
infarction, stent
thrombosis, stroke or
TIMI major bleeding)

(B)secondary ischemic
endpoint (cardiac death,

myocardial infarction,
stent thrombosis, or
ischemic stroke)
J Am Coll Cardiol 2015;65:1619–29


Bleeding in ISAR- TRIPLE
 No difference in TIMI major
bleeding between the 2
groups (5.3%vs. 4.0%; HR:
1.35; 95% CI: 0.64 to 2.84; p=
0.44)
 Any BARC bleeding occurred
in 114 patients in the 6-week
group and 122 patients in the
6-month group
(HR:0.94;95%CI:0.73to1.21;
p= 0.63)
 Intracranial bleeding
frequency was low
J Am Coll Cardiol 2015;65:1619–29


1. Compare efficacy and safety
outcomes of triple therapy vs dual
therapy (clopidogrel with aspirin or
OAC).
2. Hypothesize OAC plus clopidogrel
could be the optimal regimen for
patients with indications for OAC

receiving stent implantation.

16 eligible trials including
9185 patients
Clin. Cardiol. 38, 8, 499–509 (March 2015)


Main findings from
meta-analysis
1. Triple therapy has a similar risk of
MACE compared with dual therapy
(OR: 1.06, 95% CI: 0.82-1.39, P =
0.65)
2. The risk of all-cause mortality, MI,
and ST did not significantly differ
between the triple and dual therapy
groups
 all-cause mortality, OR: 0.98, 95% CI:
0.76-1.27,P = 0.89
 MI, OR: 1.01, 95% CI: 0.77-1.31, P =
0.97
 ST, OR: 0.91, 95% CI: 0.49-1.69, P =
0.75
Clin. Cardiol. 38, 8, 499–509 (March 2015)


Less ischemic stroke and more bleeding with triple therapy
1. Triple therapy was associated with a significantly lower incidence
of ischemic stroke (OR: 0.57, 95% CI: 0.35-0.94,P = 0.03)
2. Significantly increased major bleeding in the triple therapy group

(OR: 1.52, 95% CI: 1.11-2.10, P = 0.01), as well as minor bleeding
(OR: 1.59, 95% CI: 1.05-2.42, P =0.03)

Conclusion
 In patients taking oral anticoagulants and undergoingPCI , OAC plus
clopidogrel was associated with at least similar efficacy and safety
outcomes compared with triple therapy.
 Triple therapy regimens could be replaced by OAC plus clopidogrel
without any concern about additional risk of thrombotic events.
Clin. Cardiol. 38, 8, 499–509 (March 2015)


Herz (July 2015),DOI 10.1007/s00059-015-4325-0

1. 23 clinical trials comprised 22,212 participants
2. TT was more efficacious than DT (DAPT or OAC + single APT) in
reducing MACE/stroke (RR =0.76, 95% CI: 0.70–0.83; p< 0.00001 &
RR = 0.67,95% CI: 0.59–0.75; p< 0.00001, respectively)

3. There was a significant reduction in all-cause death in the TT
compared with the DT regimen (RR = 0.64, 95 % CI: 0.56–0.73; p <
0.00001& RR = 0.48, 95 % CI: 0.39–0.58; p < 0.00001,respectively)


More major bleeding in patients receiving TT compared
with DAPT (p < 0.00001), but…

No difference between those receiving TT and OAC + single
antiplatelet agent (RR = 0.96; 95 % CI: 0.75–1.21; p = 0.71)

Herz (July 2015),DOI 10.1007/s00059-015-4325-0


No differences in MACE/ Stroke & All- cause death
between TT and OAC+ clopidogrel

Herz (July 2015),DOI 10.1007/s00059-015-4325-0


Management of antithrombotic therapy in AF patients presenting with ACS
and/or undergoing PCI or valve interventions: a joint consensus document

European Heart Journal doi:10.1093/eurheartj/ehu298 (July 2014)