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Antiplatelet Options in the Cath Lab: How Can We Find Value? Michael J. Lipinski, MD, PhD MedStar Washington Hospital Center Michael J. Lipinski, MD, PhD Financial disclosures: Medicure Inc: Research grant and consulting A Quick Case • A 48 y/o male with PMH of CAD s/p CABG (LIMA to LAD, SVG to OM) with multiple PCI (recent stent to RCA), HTN, HLD, and ESRD on HD developed acute CP • Patient “may have forgotten to take his medications for the past week” • Transferred to the ED via EMS and ECG from EMS demonstrated Inferior STEMI • Patient received ASA 324 mg, Heparin IV bolus, and Ticagrelor 180 mg The RCA looked surprisingly good The LCX was patent in November. SVG patent to a diseased OM Following Cangrelor and Balloon Angioplasty Post-PCI Care • Groin closed with 6F Angioseal device • Cangrelor infusion continued for another 80 minutes • Admitted to the CCU • Patient stood up at 1 hour post-PCI to use his urinal • After discussion with the patient, he routinely skips his evening meds due to GERD • Switched to Clopidogrel with 600 mg load despite the presence of multiple stents Value vs Cost: Penny Wise, Pound Foolish Things that are Cheap • • • • • Clopidogrel Heparin Balloons Early Discharge Death Things that Cost More • Ticagrelor/Prasugrel • Bivalirudin • Aspiration Thrombectomy • Guideliner catheter • IV Platelet Inhibitors – Cangrelor>GPI • Major Bleeding • Stent Thrombosis • Readmission Stent thrombosis and intraprocedural thrombus impact outcomes Généreux, J Am Coll Cardiol 2014 Stent thrombosis and intraprocedural thrombus impact outcomes Généreux, J Am Coll Cardiol 2014 What are Options to Reduce PeriProcedural Stent Thrombosis • Utilization of heparin over bivalirudin • Addition of intravenous platelet inhibitors may reduce the risk of stent thrombosis • GPI use decreased the risk of stent thrombosis in the PLATO study Shimada, Am Heart J 2016 • However, rapid platelet inhibition with either Cangrelor or Glycoprotein IIb/IIIa inhibitors may increase bleeding • Furthermore, what’s the utility of intravenous platelet inhibitors in the setting of ticagrelor and prasugrel? Cangrelor can Mitigate the Risk of Stent Thrombosis when using Bivalirudin White, JACC Cardiovasc Interv 2015 Cangrelor appears to reduce ischemic events even in the setting of GPI use Vaduganathan, JACC 2017 … But at the Cost of More Bleeding Gutierrez, Eur Heart J 2016 GPI further increases bleeding risk Vaduganathan, JAMA Cardiol 2017 Can Bleeding with GPI Use be Mitigated with a Bolus-only or Short Infusion? Kini, Am Heart J 2008 Indirect Comparison of Cangrelor with Newer Oral P2Y12 Inhibitors Westman, Cardiovasc Revaasc Med 2017 Indirect Comparison of Cangrelor with Newer Oral P2Y12 Inhibitors Westman, Cardiovasc Revaasc Med 2017 Conclusions • Intravenous platelet inhibitors provide rapid platelet blockade but at the risk of increased bleeding • Further studies are needed to assess the impact of these therapies on cost • Further studies are needed to assess the utility of intravenous platelet inhibitors in the setting of increased use of newer oral P2Y12 inhibitors
