European Bifurcation Club 2021 – DAY 1
Hello my name is dominic angelido and today i’ll be speaking to you about adapt de-escalation and i’ve also introduced the concept of escalation options after bifurcation lesion with two stent techniques these are my disclosures so when we speak about the de-escalation we’re speaking about switching from plaster girl or ticago to grow as a strategy to reduce the
Long-term risk of bleeding without any trade-off in ischemic events while escalation is the switching from clutter growth to practical or tacagular as a strategy to reduce thrombotic complications without a trade-off in bleeding and what we do know is that this strategy works and more specifically when we’re speaking about a guided escalation or guided de-escalation
Approach and when we speak about guiding this is by the use of either platelet function or a genetic testing as you can see as mentioned before the concept of escalation you reduce ischemic events and thrombotic complications without a tradeoff and bleeding and while the de-escalation it’s a reduction bleeding without a trade-off in thrombotic complications now
It is important to keep in mind that when we’re speaking about bifurcation with two cent techniques this is by definition a setting of high thrombotic risk as recognized by the esc guidelines so when we’re speaking about de-escalation this by definition implies that a patient is already on a potent p2y12 inhibitor uh such as in the setting of an acute coronary
Syndrome and therefore the recommendation in general is not to de-escalate unless you have a good reason and this could be due to drug access or due to non-bleeding side effects for example disney if the patient’s anti-cancer or but for the most part that we also can consider prasargo in some of these patients if there isn’t a contraindication so truly the
Reason to de-escalate in these patients if you really have an individual who’s also at high risk for bleeding complication an hbr patient and the reason why we are concerned is very simple we know that if you de-escalate you’re going to a drug which is clopidogrel characterized by a broad degree of inter-individual variability and therefore you have a significant
Number of individuals who remain at risk for thrombotic complications so the general rule is do not escalate soon after pci and beware of the fact that you have an increase of platelet reactivity due to a number of reasons one you’re switching to a less potent p2y12 inhibitor with clutter growth you have the pro-thrombotic environment a post-pci particularly for
The setting of an acute coronary syndrome and let’s not forget that when you switch particularly going from ticago to clopidogrel there is a risk of drug drug interactions and we have plenty of data to support this this is one of the many registries such as the scope registry showing that when you switch early particularly in the early post-pci phase and this is
Again it’s not specific to bifurcation this is specifically a patient with acute coronary syndrome there is an increase in thrombotic complications so definitely we would not want to put ourselves in this position particularly if we have a patient with recently treated with two stents for bifurcation in the setting of acupuncture syndrome the second rule that we
Should consider is that consider waiting at least 30 days before de-escalating and ideally the escalation should occur when guided by platelet function or genetic testing as i already mentioned before now each one of these tests have pros and cons one of the things to keep in mind that if you’re considering de-escalating to clepitogral and you want to understand
The response platelet function testing may not be the best option because the patient actually needs to be on the drug to the fine response and so sometimes it may be a little bit too late to understand whether it’s worthwhile to be on clopidogrel or not if you’re just relying on platelet function testing and this is the advantage of genetic testing because
Genes don’t change and the only issue is that genetic testing is not always a direct measure of response but we can improve the accuracy by the way which we use genetic testing and predict response by using a score this is the abcd gene score which integrates genetic information together with clinical information a b c and d in other words age body mass index
Chronic kidney disease and diabetes diabetes each one with a an integral scoring system and if the score is above 10 you have a very high likelihood of being a poor responder to clopidogrel this is something that we do use in our uh in our practice now that we have rapid genetic testing assays that give you a result within one hour now an alternative of the
De-escalation although it’s really not the true concept of the escalation i’m going from a more potent to a less potent p to a 12 inhibitor but yes considering uh uh reduction in antithrombotic agents is that of stopping aspirin and you can uh see here there’s an analysis from the twilight complex uh uh uh the twilight side which is a twilight complex uh analysis
Which did include as one of the anatomical factors of bifurcation with two stent techniques and what we learned from this analysis uh uh published by george danges in in jack is that there is consistency with the overall trial findings so a significant reduction in bleeding without any trade-off and ischemic events when it comes to escalation this implies that
A patient is on the pitogrel such as the patient with stable cad and it’s a reasonable approach if a patient is not at high bleeding risk if you’re considered concerned about poor plutical response in my practice i consider practical over ticagular if there are no contraindications simply because practical is a true pci drug it’s a once daily regimen there is no
Dyspnea and there are no concerns about drug interactions when switching back to clepitograph if uh needed at a certain uh point so again it’s not because there is any specific pharmacodynamic difference i just think it’s it is a more user-friendly uh approach to consider a password if there aren’t any uh contraindications and uh last but not least uh when when
Switching whether this is a de-escalation or escalation always switch to the alternative agent using a loading dose administration and you probably want to do that 12 to 24 hours after the last maintenance dose of the drug if you’re doing a de-escalation strategy instead if you’re doing an escalation strategy it really doesn’t matter you can do it even right away
Because there aren’t interactions when you escalate to a more potent pty-12 inhibitor thank you very much for your attention
Transcribed from video
DAPT de-escalation options after bifurcation lesion 2-stent PCI/DES – Dr Dominick ANGIOLILLO By European Bifurcation Club
