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Arrêtez de prArrêtez de préé--traiter les SCAtraiter les SCA !!03Gilles MontalescotGilles Montalescot
Dr. Montalescot reports research Grants to theInstitution or Consulting/Lecture Fees from Abbott, AIM group, Amgen, Actelion, ACC Foundation, Astrazeneca, Axis-Santé, Bayer, Boston-Scientific, BMS, Beth Israel Deaconess Medical, Brigham Women’s Hospital, Fréquence Médicale, ICOM, Idorsia, Elsevier, ICAN, Lead-Up, Menarini, MSD, Novo-Nordisk, Pfizer, Quantum Genomics, Sanofi-Aventis, SCOR global life, Servier, WebMD.
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www.action-groupe.orgParis, France
2nd generation P2Y12 antagonists
Wiviott S et al. NEJM 2007;357:2001-15
TRITON PLATO
Pre-treatment definition
The term “pretreatment” refers to the initiation of a treatment (P2Y12 inhibitor) prior to the definition of coronary anatomy.”
ACCOAST
ACCOAST Primary Efficacy and Safety Endpoints
Days From First Dose
0 5 10 15 20 25 30
En
dp
oin
t (%
)
0
5
10
15
No Pre-treatment10.8
HR, 1.02 (95% 0.84, 1.25) P=0.81
19962037
17881821
17751809
17691802
17621797
17521791
CV Death, MI, Stroke, UR, GPIIb/IIIa Bailout Pre-treatment
10.8
16211616
No. at Risk, PrimaryEfficacy End Point:No pre-treatmentPre-treatment
HR, 0.997 (95% 0.83, 1.20)P=0.98
Pre-treatment10.0
No Pre-treatment9.8
Days From First Dose
0 5 10 15 20 25 30
En
dp
oin
t (%
)
0
1
2
3
4
5
Pre-treatment2.9
No Pre-treatment1.5
HR, 1.97 (95% 1.26, 3.08)P=0.002
All TIMI Major Bleeding
HR, 1.90(95% 1.19, 3.02) P=0.006
Pre-treatment2.6
No Pre-treatment1.4
19962037
1947
1972
1328
133912971310
12881299
1284
1297
1263
1280
No. at Risk, All TIMI Major Bleeding:
No pre-treatment
Pre-treatment
Montalescot G et al. N Engl J Med.2013;369:999-1010
Pre-treatment in NSTEMI/PCI10
5
0
En
dp
oin
t (%
)
0 5 10 30
Days from first dose
HR 1.05 (95% CI: 0.82–1.34)
p=0.72
15 20 25
HR 3.11(95% CI: 1.86–5.22)
p<0.001
CV death, MI or stroke
Non-CABG-related TIMImajor or minor bleeding
9.2
4.2
8.8
1.4
No pre-treatment
Pre-treatment
HR 1.01 (95% CI: 0.78–1.31)
p=0.92
HR 2.94(95% CI: 1.67–5.18)
p<0.001
8.5
3.4
8.4
1.2
No pre-treatment
Pre-treatment
Montalescot et al. JACC2014;64:2563–71
PCI cohort
Risk of waiting in NSTEMI
Early P2Y12 inhibition
Tarantini G, et al. J Am Coll Cardiol. 2020;76:2450-9
45
Days since randomisation
30150
0.00
0.01
0.02
0.03
0.04
Cu
mu
lati
ve
in
cid
en
ce
p=0.50
Ticagrelor
Montalescot G, et al. N Engl J Med. 2013;369:999-1010
Prasugrel
Days from first dose
Pati
en
ts w
ith
En
dp
oin
t E
ve
nt
(%)
No Pre-treatment10.8
HR, 1.02 (95% 0.84, 1.25) P=0.81
CV Death, MI, Stroke, UR, GPIIb/IIIa Bailout Pre-treatment
10.8
HR, 0.997 (95% 0.83, 1.20)P=0.98
Pre-treatment10.0
No Pre-treatment9.8
300 5 10 15 20 25
15
10
5
0
67% ACS 13% ACS 100% ACS
Clopidogrel
CREDO PRAGUE-8 ARMYDA-5PRELOADp=0.23
Steinhubl S, et al. JAMA. 2002;288:2411-20
915900
839838
834836
834834
832832
Time from randomisation (days)
Co
mb
ined
en
dp
oin
t o
ccu
rren
ce (
%)
0 7 14 21 28
10
9
0
8
7
6
5
4
1
2
3
In lab loadPreload
0.8% 1.0%
Widimski P, et al. Eur Heart J. 2008;29:1495-503
Death/MI/stroke/re-interventionwithin 7 days
p=0.75
Di Sciascio G, et al. J Am Coll Cardiol. 2010;56:550-7
Days after PCI20 25 305 10 15
Days after PCI
Cu
mu
lati
ve in
cid
en
ce o
f M
AC
E (
%)
20
16
12
8
4
0
p=0.72
No pretreatmentPretreatment
Early GPI in NSTEMI
How to treat in cathlab?
Crushed prasugrel
Orodispersible ticagrelor
Cangrelor
GPI (High risk or BO)
Game over for pretreatment!
DOES PRE-TREATMENT REALLY BENEFIT NSTE-ACSPATIENTS UNDERGOING PCI?
DOES PRE-TREATMENT REALLY HARM NSTE-ACS PATIENTS NOT UNDERGOING PCI?
WHAT IS THE ISCHEMIC RISK OF WAITING WITHOUT PRE-TREATMENT?
ARE REAL-LIFE DATA DIFFERENT?
WHAT DO THE GUIDELINES SAY?
WHAT SHALL WE DO?
ESC Guidelines 2020
Conclusions
In NSTEMI, pre-treatment = over-treatment
In NSTEMI, double antiplatelet therapy if conservative strategy or long wait for cathlab
In NSTEMI, single antiplatelet therapy before early angiogram
01
02
03
