Interventional cardiology ,PCI for Acute coronary syndromes. P2Y12 inhibitors

1. P2Y12 inhibitors during PCI for
Acute coronary syndromes
By
Ahmed Kamel,MD,FEBC,FSCAI
National Heart institute
2018

2. What are the P2Y12 inhibitors currently used?
• Clopidogrel : Prodrug that needs activation by
Cytochrome P450,irreversible platelet inhibition.
• Ticagrelor: Active drug (rapid onset of action),rapid
offset,reversible platelet inhibition. PLATO
• Prasugrel: Prodrug,irreversible platelet
inhibition.(not available in Egypt) has 3
contraindications. TRITON TIMI 38

3. PLATO trial

4. Methods
• In this multicenter, double-blind, randomized trial,
they compared ticagrelor (180-mg loading dose, 90
mg twice daily thereafter) and clopidogrel (300-to-
600-mg loading dose, 75 mg daily thereafter) for
the prevention of cardiovascular events in 18,624
patients admitted to the hospital with an acute
coronary syndrome, with or without ST-segment
elevation.

5. Results
• At 12 months, the primary end point ,
(a composite of death from vascular causes,
myocardial infarction, or stroke ) had occurred in
9.8% of patients receiving ticagrelor as
compared with 11.7% of those receiving
clopidogrel P<0.001

6. Incidence of Bleeding
• No significant difference in the rates of major
bleeding was found between the ticagrelor
and clopidogrel groups (11.6% and 11.2%,
respectively; P=0.43),

7. Conclusions
• In patients who have an acute coronary syndrome
with or without ST-segment elevation, treatment
with ticagrelor as compared with clopidogrel
significantly reduced the rate of death from
vascular causes, myocardial infarction, or stroke
without an increase in the rate of overall major
bleeding but with an increase in the rate of non–
procedure-related bleeding.

12. September 2016

13. ½

14. Case Scenario
An 80 y old lady with low body mass index
,hypertensive ,controlled on medication,not
diabetic complained of progressive chest pain
on regular home effort over the past few days.
I saw her in an office visit ,clinical examination
was unremarkable ,ECG showed ST elevation at
the inferior leads denoting an acute inferior
STEMI

16. How should i treat?
• Primary PCI or thrombolysis?
• Primary PCI DANAMI trial
• Is it safe to use ticagrelor for loading?
• In the PLATO trial 15 % of the patients treated
by ticagrelor were above 75 years of age .
• Femoral or Radial access?
• Radial ....RIVAL ,STEMI RADIAL trials

24. Post PCI course
• After PCI ,the patient was referred to the CCU
where she stayed for two days and was
discharged home on DAPT ,Ticagrelor 90 mg
BID with Aspirin 75 mg OD,Rusovastation and
ACEI for HTN.
• I have been following her up for more than 18
months with no clinical problems.
• Did PCI for two of her family members.

25. Take home message
1.Ticagrelor is a potent P2Y12 receptor inhibitor
preferred for use in cases of both STEMI and
NSTE ACS ,yet it did not increase major bleeding
as shown in the PLATO trial.
2.Both ESC ,ACC/AHA/SCAI updates mentioned
ticagrelor as the preferred antiplatelet in cases
of ACS both STEMI and Non STE

26. Take home message cont
• 3.No contraindications for ticagrelor as
Prasugrel ,no clinical ,age or body weight
limits.
•