With W Sumaya.
Enough dr. su yama thank you very much that’s great it’s better to be here with you today and thank you to the organizers for organizing this exciting meeting i’m think it still calm behalf of professor story from sheffield who unfortunately couldn’t be with us today due to bike accident rob’s disclosures so there are three areas where i would like to discuss with
You today where there are opportunities and challenges for antithrombotic therapy and stroke risk reduction also straight through prevention so the patients who have who are at high risk for effort from buttock disease and that implications with coronary artery disease and/or prefer artery disease with multiple risk factors the other patients are patients with
Atrial fibrillation and who also need an to play therapy either because they’ve had pci or presented with acute coronary syndromes and lastly patients who present with – strokes or cia so the first cohort of patients patients who have coronary artery disease and autism with multiple risk factors and there are two main trials that that have addressed this issue
So the pegasus timi 54 trial was aiming to locations where within one to three years of having a myocardial infarction they had to give us a teenager over 15 have also additional risk factors either diabetes but a disease or chronic kidney disease not needing dialysis and compared to anti-alias era pea with aspirin and ticagrelor two different doses to aspirin
Monotherapy alone and we can see in this slide that acog you know that very well introduced major cardiovascular events significantly compared africana therapy and when we look at the number of strokes in patients who received chicago 60 milligrams twice daily and as they approved those four pronged absolutely there is a significant reduction and the moderate
Is really disabling stroke and these indications of course there is a penalty and that was at the expense of increase in non-fatal major bleeding events and as you can see that there is no difference in fatal bleeds or intracranial hemorrhage between patients were an adapt or an aspirin mono therapy and now takagi law works by inhibiting platelet so it inhibits
Platelet receptor and we know that playlet and coagulation isn’t it’s very closely linked so they activated platelets play an important role in from a generation and from been generation so by inhibiting platelets with that here are 12 inhibitors that may have an indirect auntie carolyn effect buying everything from ben’s generation sorry similarly when we live
Anticoagulants that inhibits thrombin generation and thrombin is a very powerful platelets agonist through the power receptors so and silence may have an indirect antiplatelet effect so that leads us to question with anticoagulants may play a role as well so we know that there’s sort of the compressed trial so compass’ recruited high-risk patients for a traumatic
Disease and that includes patients with coronary artery disease who have multi vessel chronic disease and and all prefer artery disease and 60 percent of patients had marker unfortunate earth and they compared the addition of low-dose reverse 12.5 milligrams twice daily in addition to aspirin to aspirin alone or rivaroxaban five milligrams twice a day compared to
Aspirin alone and as you can see the combination of aspirin and rivaroxaban did very well and they improved major cardiovascular events including in a ghastly death whereas the river reverbs ban alone treaty group didn’t significantly they reversed vanillin didn’t significantly reduce a risk of major cardiovascular events so this indicate that seventy plato therapy
Is needed in this cohort and if we look at the stroke risk reduction in composite it was very impressive so there is 42 percent risk reduction in terms of stroke so that is really highly significant very impressive of course that was at the expense again for an increased risk of non-fatal major bleeding’s you can see that a fatal intracranial hemorrhage were
No different to injure aunty from buttock 31 and rivaroxaban compared to aspirin alone so we move on to the the other complex issue which is asians who need and play therapy because of pci or and acute coronary syndrome but also need and coagulation before because of atrial fibrillation this is a very complex area there were two major trials that the pioneer and
Redraw pci they had some limitations for example pioneer tested low dose 15 milligrams as a joule therapy approach with peter grill competitor therapy with warfarin so it’s not really a fair comparison and also tested triple therapy with a non approved dose of rivaroxaban two point five milligrams twice daily and clopidogrel and regional pci again had the similar
Limitations nevertheless there is a consensus document and evidence and in patients who have a high risk who are it’s hard for fatal bleeds or and oral anticoagulants and an anti patient may be acceptable immediately after piece of course for those for higher expose implements triple therapy is still indicated we’re waiting for the results of the august’s trial
Which is due to be announced in the acc meeting this year and augustus was a much bigger study so recruits at 4,600 patients and and compared vitamin k antagonists to a noack in this case a big sedan and also tested and dropping aspirin to see whether we can do with just joule therapy from the start so we look forward really to the results of this because we’re
Going to feel further and if we move on to patients who presented the iron – stroke you know the aspirin as indicated but is there a role for a dual antiplatelet therapy approach there were three but the meta-analysis of this of these three trials indicated therapy with aspirin doesn’t really very few aspirin and clopidogrel reduce the recurrence of a stroke and
Without ectly a penalty of increased may leading risk however the all cause mortality for jewel and splinter apologies for this slide doesn’t so they’re all cause mortality for the damps the contestant doesn’t really favor dual antiplatelet therapy approach and this publishing so the practice trial tested whether chicago all mono therapy is better than aspirin
Therapy in those who present with the ti or minor stroke there was a trend for benefits with chicago but this missed significance b value of no point no seven so so so this led us to question is joyful aspirin seek a closed beneficial so so group analysis was done and patients were pre treated with aspirin before the trial and then they received tikka glow and did
Well and so this is of course hypothesis generating a generating finding and on the basis of that the thalis studies on ongoing now so this is testing aspirin jolin’s player therapy twenty low compared to aspirin and those who present to the ti airman is or or a small stroke so in conclusion and there is a role for intensive antithrombotic therapy whether that
Is with aspirin and tickled 60 milligrams twice daily in those who have had a contraction with additional risk factors or aspirin and rivaroxaban two point five meters wide daily and those who have multi vessel coronary artery disease and or peripheral artery disease and that leads to a reduction in stroke risk in patients who have acs or all who have had pci and
Also need anticoagulation for each of the relation and we acknowledge that this is a very complex area but the result of the peg is air of the augusta study and the acc will inform the field further currently only in very high-risk patient bleeding risk patients around carolyn’s and an antiplatelet agent is recommended patients with a ti or minus stroke aspirin
And clopidogrel reduced three tons of stroke there is there was no evidence of improved mortality with this approach apparently the salus study is ongoing to test whether aspirin chicago may be the period aspirin monotherapy and with that i’d like to end the token thank you very much for everything
Transcribed from video
Patients with high risk of stroke By European Society of Cardiology
