ACS from Diagnosis to Long Term

Treatment: Focus on oral Antiplatelet

Rony M Santoso, MD
FIHA, FAPSC, FESC, FSCAI
 Curriculum Vitae
EMPLOYMENT HISTORY AND POSITION NOW
- Interventional Cardiologist and Vascular Medicine Consultant at OMNI
International Hospital, Alam Sutera, Tangerang (2018-now)
- Head of Catheterization Laboratory at Primaya Hospital, Tangerang (2012-
now)
- Interventional Cardiologist and Vascular Medicine Consultant at Anisa
Hospital,
Tangerang (2018-now)
- Indonesian Heart Association’s Instructor for Advanced Cardiac Life
Support (ACLS)
and Basic Cardiac Life Support (BCLS) (from 2012-now)
- Peri operative, Shock and Critical Care Course (Society of Critical Care
Medicine)
as Instructor
Management of STEMI – PERKI - 2018
 Adjunctive Treatment in Primary PCI &
Fibrinolytic Therapy
Primary PCI Fibrinolytic

Antiplatelet • Ticagrelor 180 mg + 90 mg • Clopidogrel*

BID * If patient undergoing PCI after
• Clopidogrel 600 mg + 75 mg fibrinolytic, may consider to
switch to ticagrelor
OD, if ticagrelor is not
available or contraindicated
Anticoagulant • UFH, if patient can not • Enoxaparin sc
received bivalirudin or • UFH iv
enoxaparin • Fondaparinux bolus + sc
• Enoxaparin for 24 hours -
streptokinase
GPIIb/IIIa Only for no reflow or thrombotic
complication
Reference: 1. Buku Pedoman Tatalaksana Sindrom Koroner Akut, Perki 2018
 Ticagrelor Is Recommended as First Line
OAP for STEMI Based on ESC Guideline1,2

Recommendations Class Level

Guideline
Antiplatelet therapy

A potent P2Y12 inhibitor (prasugrel or ticagrelor), or clopidogrel if

these are not available or are contraindicated, is recommended
ESC 20171 I A
before (or at latest at the time of) PCI and maintainded over 12 months,
unless there are contraindications such as excessive risk of bleeding.

A P2Y12 inhibitor is recommended in addition to ASA and maintained

over 12 months unless there are contraindications such as excessive risk I A
2014 of bleeding.
ESC/EACTS
Myocardial Ticagrelor (180 mg loading dose, 90 mg twice daily) if no
I B
Revascularizatio contraindication
n2
Clopidogrel (600 mg loading dose, 75 mg daily dose), only when prasugrel
I B
or ticagrelor are not available or are contraindicated.

Reference:
1. Ibanez B et al. European Heart Journal 2017; 00; 1–66.
2. 2. Windecker S. et al European Heart J. 2014; 1-12
Guideline and Consensus Recommendation
on Antiplatelets

Reference:
1.Ibanez B et al. European Heart Journal (2017) 00, 1–66; 2.Dr Jack Tan. ESC Asia 2019 presentation. APSC Consensus Statement Updates
2. Tobing DL et al. Indonesia J Cardiol.2019;40:309-311.
 ESC 2017 Focused Update DAPT in CAD :
Algorithm for switching between oral P2Y12 inhibitors
in ACUTE setting 1

Class I LOE B
Class Iib LOE C

Switch from Clopidogrel to Ticagrelor in Acute Setting is allowed

irrespective of prior clopidogrel timing and dosing (1B)

Reference: 1. Valgimigli M et al. European Heart Journal (2017) 0, 1–48 10

 Key Steps on NSTEACS Management Strategy1

Step 1. initial evaluation

Step 2. Diagnosis validation, risk assessment and

rhythm monitoring

Step 3. invasive strategy

Step 4. revascularization modalities

Step 5. hospital discharge and post-discharge

management

11
Reference: 1. Roffi M et al. European Heart Journal 2015. doi:10.1093/eurheartj/ehv320
NSTEACS Treatment Strategy and Timing According
to Risk Stratification1

Reference: 1. Adapted from : Roffi M et al. Eur Heart J 2016;37(3):267-315

 Risk Criteria Mandating Invasive Strategy in NSTE-ACS1

• Hemodynamic instability or cardiogenic • Relevant rise or fall in troponin

VERY HIGH RISK

shock • Dynamic ST- or T-wave changes

HIGH RISK
• Recurrent or ongoing chest pain (symptomatic or silent)
refractory to medical treatment • GRACE Score > 140
• Life-threatening arrhythmias or cardiac
arrest
• Mechanical complications of MI
• Acute heart failure
• Recurrent dynamic ST-T wave changes,
particularly with intermittent ST-elevation
INTERMEDIATE

• Diabetes mellitus • Any characteristics not mentioned

• Renal insufficiency above

LOW RISK
(eGFR <60 mL/min/1.73 m²)
• LVEF < 40% or congestive HF
• Early post infarction angina
• Prior PCI
• Prior CABG
• GRACE risk score 109 - 140

Reference: 1. Roffi M et al. Eur Heart J 2016;37(3):267-315

 Risk Stratification: GRACE Score1

Points for Each Predictive Factor

Killip Score SBP, Score
Class Mm Hg
I 0 < 80 63
II 21 80 – 99 58 High risk: Score >140
III 43 100 - 119 47
IV 64 120 - 139 37 In-hospital death: >3%
Heart Rate, Score 140 - 159 26
Beats/min 160 - 199 11
> 200 0
< 70 0
Age Score
70-89 7
90-109 13 < 40 0
Intermediate risk: 109 – 140
110 - 149 23 40 - 49 18 In-hospital death: 1-3 %
150 - 199 36 50 - 59 36
> 200 46 60 - 69 55
Predictive Score 70 – 79 73
Factor 80 91
Creatinine, Score Low risk: Score ≤ 108
• Cardiac • 43 (µmol/L)
arrest at • 15 In-hospital death: <1%
admission • 30 0 - 34 2
• Elevated 35 – 70 5
cardiac 71 – 105 8
markers 106 – 140 11
14

• ST Segment 141 – 176 14

deviation 177 – 353 23
≥ 354 31

Reference: 1. Khalill R et al. Exp Clin Cardiol.2009; 14(2): e25 – e30; 2. Hamm CW et al. Eur Heart J. 2011
16

Cath lab or later ?

Benefit of early intervention in high risk patients

Kaplan–Meier Cumulative Risk of the Primary Outcome (death, myocardial infarction, or stroke),
Stratified According to GRACE Risk Score at Baseline.

Mehta, SR et al. N Engl J Med 2009;360:2165-75.

 DAPT for 12 Months is Standard of Treatment in ACS*
ACS

PCI (DES/BMS or DCB) Medical Treatment Alone

High Bleeding Risk

No Yes No Yes

A P A T A C or A T A T A C

or or
A C
A C

12 month DAPT 6 month DAPT 12 month DAPT ≥1 month DAPT

(class I A) (class IIa B) (class I A) (class IIa C)

*If no high bleeding risk

Valgimigli M et al. European Heart Journal.2017; 0: 1–48
DAPT for 12 months is standard care in ACS, unless in HBR
 Increased risk of NACE (Net Adverse Clinical Events with
de-escalation)1

Figure 1. In-hospital relative incidence of NACE, MACE, and single adverse events in patients treated with old or novel P2Y12
receptor inhibitors (without switching) and in patients who received a switch (downgrade, upgrade or change) of oral antiplatelet
therapies during the hospitalisation.

19
Reference: 1. De Luca L et al. EuroIntervention 2017; 13(4): 459–466.
Risk Score To Decide Duration Of Treatment

Valgimigli M et al. European Heart Journal. 2018) 39, 213–254

 Key Learning

• Shorter delays to reperfusion result in improved mortality outcomes.

• Risk stratification is important in NSTEACS to define the right

patients for aggressive approach

• DAPT for 12 months is standard care in ACS, unless in high bleeding

risk patients

• Ticagrelor provides superior efficacy by reducing CV event without

increasing risk of major bleeding vs. clopidogrel

• Ticagrelor as more potent OAP, has been recommended by

international and local guidelines as preferred OAP for ACS
CONCLUSIONS

• In STEMI, treat early, treat strong !!

• In NSTEMI, right antiplatelet therapy especially in early

invasive strategy

• Duration of DAPT is one year after ACS but evaluation of

risk/benefit is necessary to shorten or prolong

• Re-evaluate regularly risk / benefit of DAPT according to

disease evolution and patient’s preference
 Bleeding Management on DAPT (1/2)

Valgimigli M et al. European Heart Journal (2017) 0, 1–48 24

 Bleeding Management on DAPT (2/2)

Valgimigli M et al. European Heart Journal (2017) 0, 1–48 25