CardioScripts Classic – Antiplatelets in ACS [Part 2]

0:00-0:58: Intro

0:59-4:47: 1-year after ISAR-REACT 5, does prasugrel reign supreme?

4:48-7:32: Dr. Dunn and Dr. Macaulay dive into the confusing world of DAPT duration.  Who should get shorter and who get longer, based on DAPT trial, PEGASUS, TWILIGHT, TICO, and more. 

7:33-10:46: When de-escalation is indicated, should it be aspirin or P2Y12 inhibitor that goes away?  Remember CAPRIE?

10:47-13:56: ESC meeting and presentation of 2020 Guidelines for NSTE ACS recommend prasugrel, 12-months for most (but lots of wiggle room), and no upfront treatment with P2Y12. 

13:57-15:41: Pre-treatment with P2Y12 inhibitors or not?  Where is the data for what has become widespread practice.

15:42-20:08: A review of switching between P2Y12 inhibitors.  And defining a role for improved pharmacy continuity between inpatient, ambulatory and community pharmacists.

20:09-20:52: Closing 

References:

• Schupke S, et al. Ticagrelor or prasugrel in patients with acute coronary syndromes (ISAR-REACT 5). N Engl J Med 2019. (epub doi 10.1056/NEJMoa1908973):1-11.
• Mauri L, et al. Twelve or 30 Months of Dual Antiplatelet Therapy after Drug-Eluting Stents (DAPT Study). N Engl J Med 2014; 371:2155-2166.
• Bonaca MP, et al. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med 2015;372:1791-1800.
• Costa F, et al. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trial. Lancet 2017;389:1025-1034.
• Mehran R, et al. Ticagrelor with or without Aspirin in High-Risk Patients after PCI (TWILIGHT). N Engl J Med 2019; 381:2032-2042.

• Kim B, et al. Effect of Ticagrelor Monotherapy vs Ticagrelor With Aspirin on Major Bleeding and Cardiovascular Events in Patients With Acute Coronary Syndrome. The TICO Randomized Clinical Trial. JAMA 2020;323(23):2407-2416.
• Gent M, et al. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996;348:1329-39.
• Montalescot G, et al. Pretreatment with Prasugrel in Non–ST-Segment Elevation Acute Coronary Syndromes (ACCOAST). N Engl J Med 2013;369:999-1010.
• Steinhubl SR, et al. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial (CREDO). JAMA 2002; 20;288(19):2411-20.
• COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group. Addition of clopidogrel to aspirin in 45 852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 2005; 366: 1607–21.
• Bhatt DL, et al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events (CHARISMA). N Engl J Med 2006;354:1706-1717.
• Collet JP, Thiele H, Barbato E, et al.2020 ESC Guidelines for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-Segment Elevation: The Task Force for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2020;Aug 29:[Epub ahead of print].
• Navarese EP, Khan SU, Kołodziejczak M, et al. Comparative Efficacy and Safety of Oral P2Y12 Inhibitors in Acute Coronary Syndrome: Network Meta-Analysis of 52,816 Patients From 12 Randomized Trials. Circulation 2020;May 29:[Epub ahead of print].
• Tarantini G, et al. Timing of Oral P2Y₁₂ Inhibitor Administration in Non-ST Elevation Acute Coronary Syndrome. Journal of the American College of Cardiology August 2020:DOI: 10.1016/j.jacc.2020.08.053.
• Classens DMF, et al. A Genotype-Guided Strategy for Oral P2Y₁₂ Inhibitors in Primary PCI (POPULAR GENETICS). N Engl J Med 2019; 381:1621-1631.