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Core Curriculum

• Antiplatelet Interventions in ACS



Antiplatelet Interventions in Acute Coronary Syndromes

Download VBWG06-CoreACS-S01.ppt (16 slides - 1.3MB)

Antiplatelet Interventions in Acute Coronary Syndromes Contents Acute Coronary Syndromes: Tailoring Treatment to Level of Risk US hospital discharges: Unstable angina/NSTEMI and STEMI ACC/AHA 2002 UA/NSTEMI guidelines: High-risk indicators for early invasive strategy Invasive Rx in ACS: Early and late mortality Invasive management of UA/NSTEMI meta-analysis: Subgroups RITA 3: Benefit of routine invasive strategy mainly in high-risk patients RITA 3: Greater benefit of early invasive strategy in men vs women with ACS FRISC II: Men with ACS show greater benefit from early invasive strategy than women Release of cardiac troponins and CK-MB in acute MI In-hospital mortality higher with any degree of troponin elevation in NSTEMI patients TIMI risk score for UA/NSTEMI TIMI risk score in UA/NSTEMI Multimarker strategy: Identifying high-risk patients by troponin I, CRP, and BNP Multimarker approach in ACS

Thrombus Susceptibility and the Vulnerable Plaque

Download VBWG06-CoreACS-S02.ppt (10 slides - 1.9MB)

Thrombus Susceptibilityand the Vulnerable Plaque Interaction between inflammation and hemostasis in vulnerable plaque Txnip links shear stress to inflammation Platelet adhesion and aggregation Platelets release soluble CD40 ligand (sCD40L) after thrombin stimulation Recombinant sCD40L enhances platelet release of reactive oxygen species GP IIb/IIIa antagonists block sCD40L release from platelets Points of action for antithrombotics Proposed model for optimal use of GP IIb/IIIa inhibitors Potential mechanisms for reduction of thrombo-inflammation with GP IIb/IIIa inhibition

ACC/AHA UA/NSTEMI Guidelines: Role of GP IIb/IIIa Inhibitors

Download VBWG06-CoreACS-S03.ppt (6 slides - 1.0MB)

ACC/AHA UA/NSTEMI Guidelines: Role of GP IIb/IIIa Inhibitors ACC/AHA guidelines for UA/NSTEMI: GP IIb/IIIa inhibitors ACC/AHA UA/NSTEMI Guidelines: Management of high-risk patients Mortality risk is lower with early (<24-hour) GP IIb/IIIa inhibition Recommended therapies for UA/NSTEMI Majority of ACS patients undergo catheterization

Clinical Trials of GP IIb/IIIa Inhibition

Download VBWG06-CoreACS-S04.ppt (28 slides - 1.5MB)

Clinical Trials of GP IIb/IIIa Inhibition Clinical Trials of GP IIb/IIIa Inhibition Efficacy of GP IIb/IIIa inhibition on death or MI in PCI or ACS PRISM-PLUS: Study design PRISM-PLUS: Benefits at 30 days similar with/without PCI PRISM-PLUS: Benefit of GP IIb/IIIa inhibition by risk profile  PURSUIT: Study design PURSUIT: Pre-PCI GP IIb/IIIa inhibition prevents early MI PURSUIT: GP IIb/IIIa inhibition prevents death with/without early PCI PURSUIT: Importance of timing GP IIb/IIIa inhibition on outcomes TACTICS-TIMI 18: Study design TACTICS-TIMI 18 vs TIMI IIIB: Effects of early PCI GP IIb/IIIa inhibition TACTICS-TIMI 18: Duration of GP IIb/IIIa inhibitor pre-PCI influences TIMI flow Clinical Trials of GP IIb/IIIa Inhibition ESPRIT: Study design ESPRIT: Outcomes at 48 hours ESPRIT: Primary outcome over time GP IIb/IIIa inhibition in planned PCI Timing of catheterization: Weekday vs weekend hospital admission Weekend delay in catheterization does not increase adverse events Clinical Trials of GP IIb/IIIa Inhibition Accelerated CAD progression in diabetes Altered platelet functions in diabetes PURSUIT: Outcomes in diabetic vs nondiabetic US patients PRISM-PLUS: Outcomes in diabetic NSTEMI patients by treatment strategy TACTICS-TIMI 18: Death/MI/ACS in ACS patients with/without diabetes EPISTENT, ESPRIT: Effect on 1-year mortality in planned PCI by diabetes status PCI in patients with ACS and diabetes

Clinical Insights, Risk Stratification, and Enhancing Outcomes

Download VBWG06-CoreACS-S05.ppt (33 slides - 1.6MB)

Clinical Insights, Risk Stratification, and Enhancing Outcomes CRUSADE: National quality improvement initiative CRUSADE: In-hospital mortality by age and acute treatment CRUSADE: Post-admission MI vs use of recommended therapies CRUSADE: Impact of early aggressive management strategy on in-hospital mortality CRUSADE: NSTE ACS dosing of antithrombotics—Study overview VBWG VBWG Results: Antithrombotic therapy dose and major bleeding Recommended dosing of antithrombotic agents Creatinine clearance vs age Clinical implications Clinical Insights, Risk Stratification, and Enhancing Outcomes INTERACT: Study design INTERACT: LMWH/UFH plus GP IIb/IIIa inhibitor in UA/NSTEMI—Primary outcomes INTERACT: LMWH/UFH plus GP IIb/IIIa inhibition in UA/NSTEMI SYNERGY: Study design SYNERGY: Enoxaparin vs UFH with GP IIb/IIIa inhibition in ACS with early PCI PCI-CURE: Substudy design PCI-CURE: Reduction in primary outcome at 30 days ISAR-REACT: Study design ISAR-REACT: Timing of loading dose and primary outcome ISAR-CHOICE: No additional platelet effect with doses >600 mg ISAR-SWEET: Study design ISAR-SWEET: Neutral effect on primary outcome in diabetes ISAR-SWEET: Reduction in restenosis and target vessel revascularization in diabetes CLEAR PLATELETS: Study design CLEAR PLATELETS: Platelet effects vs clopidogrel dose and GP IIb/IIIa inhibition CLEAR PLATELETS: Effect of clopidogrel dose and GP IIb/IIIa inhibition on cardiac biomarkers Clopidogrel response variability: 300 mg vs 600 mg Clopidogrel resistance associated with increased CV risk REPLACE-2: Study design REPLACE-2: Death, MI, urgent revascularization, major bleeding

GP IIb/IIIa Inhibition in STEMI: Growing Clinical Trial Evidence

Download VBWG06-CoreACS-S06.ppt (11 slides - 1.2MB)

GP IIb/IIIa Inhibition in STEMI: Growing Clinical Trial Evidence PCI vs fibrinolysis in STEMI patients: Short-term clinical outcomes PCI vs fibrinolysis in STEMI patients: Long-term clinical outcomes ACC/AHA STEMI guidelines: Assessing reperfusion options TIMI flow grade Mortality benefit of primary PCI declines with PCI-related time delay Major considerations for pharmacologic approaches to facilitate primary PCI INTAMI pilot trial: Early eptifibatide improves TIMI 3 flow before PCI for STEMI TIMI 3 patency before PCI in trials of early vs late/no GP IIb/IIIa inhibitors in STEMI GP IIb/IIIa inhibitors for primary PCI Facilitated PCI in STEMI
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