FOLLOW US now and be there! @DLBHATTMD @DrMauricioCohen @SVRaoMD @HeartBobH @HeartOTXHeartMD @Heart_SCCT @TCTMD @GreggWStone @gabrielsteg @cpcannon @agtruesdell @evandrofilhobr @SCAI @SripalBangalore @mmamas1973 @SABOURETCardio @PCRonline @Pooh_Velagapudi #CardioTwitter pic.twitter.com/hWctGIOjnz
— cardio-met (@cardiomet_CE) October 15, 2021
2) This series is supported by educational grants from AstraZeneca, Bayer, and Chiesi. Faculty disclosures are listed at https://t.co/gvXca4G9Xm.
— cardio-met (@cardiomet_CE) October 18, 2021
Let’s start with a case!
— cardio-met (@cardiomet_CE) October 18, 2021
5) The guidelines are clear on #DAPT in STEMI.
— cardio-met (@cardiomet_CE) October 18, 2021
Oral non-enteric coated aspirin (150-300mg)
If unable to swallow, 75-150 mg IV aspirin
More potent P2Y12 blockers w/rapid onset of action (ticagrelor/prasugrel) preferred over clopidogrel
Eur Heart J. 2018;39(2):119-177 pic.twitter.com/KWd4UpRxjn
7) Physical & pharmacokinetic impacts of CS ⬇️ effectiveness of oral antithrombotic Rx–impaired absorption, altered distribution, metabolism & excretion, co-administered Rx, targeted temperature mx(TTM) & use of MCS.
— cardio-met (@cardiomet_CE) October 18, 2021
Oral P2Y12 inhibitors may also have CYP450 interactions
9) Importantly, morphine & fentanyl, often given in STEMI, inhibit gastric emptying & delay absorption of oral P2Y12i’s, increasing risk of ischemic events.
— cardio-met (@cardiomet_CE) October 18, 2021
N Engl J Med. 2014 Sep 11;371(11):1016-27
Eur Heart J. 2016 Jan 14;37(3):245-52.
Thromb Haemost. 2018 Mar;118(3):601-612.
11) What about P2Y12 blockers? Again, no RCTs comparing them in #CS. Despite their greater potency, pharmacodynamic studies have shown a gap in their onset of action, especially in patients w/ STEMI or hemodynamic impairment.
— cardio-met (@cardiomet_CE) October 18, 2021
13) Anyway, back to our patient. This is his coronary angiogram. His BP is maintained with inotropes. There’s huge thrombus burden at an occluded ostioproximal LAD, a significantly diseased principal OM & diffusely diseased mid RCA with distal occlusion.
— cardio-met (@cardiomet_CE) October 18, 2021
What would you do? pic.twitter.com/a1zsOeprJA
15) Welcome back to this #tweetorial on antiplatelet tx in STEMI+CS. I am @aayshacader
— cardio-met (@cardiomet_CE) October 19, 2021
We got very limited flow after wiring w/huge thrombus burden. So we performed thrombus aspiration for this pt, then DES stenting. But remember, this is reserved for exceptional circumstances pic.twitter.com/usSqjAozDJ
17) We went ahead and stented his LAD after some predilatation. This is what it looked like soon after stenting. He was doing well with inotropic support. No chest pain. pic.twitter.com/6mKcQe3SFY
— cardio-met (@cardiomet_CE) October 19, 2021
19) What would you do now?
— cardio-met (@cardiomet_CE) October 19, 2021
a) IV Cangrelor
b) IC GPIIb/IIIa inhibitors
c) More IC heparin
d) Increase inotropes and see
Please vote!
21) Let’s look at the role of IV GPIIb/IIIa inhibitors. There are 3GPI’s: abciximab, eptifibatide and tirofiban.
— cardio-met (@cardiomet_CE) October 19, 2021
GPI’s bind to GP IIb/IIIa platelet receptor, blocking the final common pathway of platelet aggregation. Here too, there isn’t much RCT evidence in the setting of CS pic.twitter.com/AccyTW03bo
23) In the PRAGUE-7 RCT no benefit of routine pre-procedural abciximab was seen compared to its selective use in STEMI patients with cardiogenic shock undergoing primary PCI. (Acute Card Care. 2011 ;13(3):116-22) pic.twitter.com/o9YIh6MDql
— cardio-met (@cardiomet_CE) October 19, 2021
25) They also refer to concerns of oral P2Y12i interactions w/ #fentanyl infusions, given to unstable #CS patients who might be ventilated. Theoretically, fentanyl may delay oral P2Y12i absorption much more than peri-PCI morphine. Eur Heart J Cardiovasc Pharmacother 2021;7:125
— cardio-met (@cardiomet_CE) October 19, 2021
27) Interestingly, a recent observational study of short-duration tirofiban in morphine-treated STEMI pts showed significant ⬇️ acute stent thrombosis, w/acceptable bleeding penalty… but larger & prospective studies are warranted.
— cardio-met (@cardiomet_CE) October 19, 2021
(Platelets 2020;31: 174–178) pic.twitter.com/tynLoGIjTY
29) Welcome back! You are just a few clicks away from 0.5h CE/#CME credit–#physicians #nurses #pharmacists! I am @aayshacader and we are learning about optimal #antiplatelet tx in a case of #STEMI complicated by #cardiogenicshock. Thanks for joining us!
— cardio-met (@cardiomet_CE) October 20, 2021
31) Cangrelor is the only IV P2Y12 inhibitor. it has been extensively studied in the CHAMPION trials for pre, peri & post-PCI. We could have given him Cangrelor upfront at the start of PCI, or when we noted peri-procedural complication of no reflow. pic.twitter.com/zi4jbR3zIU
— cardio-met (@cardiomet_CE) October 20, 2021
33) Cangrelor is a nonthienopyridine ATP analog. It reversibly binds the P2Y12 receptor, has a short half-life, a rapid onset & offset of action. It has no CYP interactions. As it’s given IV, there are no interactions with opiates either. pic.twitter.com/2hx0MTekvp
— cardio-met (@cardiomet_CE) October 20, 2021
34) Some more insight into its pharmacokinetics: The CANTIC trial showed that the addition of #cangrelor leads to prompter & more potent platelet inhibition compared with crushed #ticagrelor alone, in STEMI patients undergoing primary PCI. pic.twitter.com/Q5MtOPQ1Gr
— cardio-met (@cardiomet_CE) October 20, 2021
36) The use of Cangrelor as a bridge to avoid surgical delays is especially important in STEMI shock cases. Some of them might be in shock due to mechanical complications of STEMI such as free ventricular wall rupture/ ventricular septal defects & need emergent surgery.
— cardio-met (@cardiomet_CE) October 20, 2021
38) So, when and how do we load?
— cardio-met (@cardiomet_CE) October 20, 2021
Here's a neat guide: pic.twitter.com/jynL4kSp17
40) These are notorious for both bleeding & ischaemic complications- often occurring simultaneously. Here, greater attention to detail, to maintain a fine balance between the many antithrombotic therapies, is needed. Here’s a neat summary of action points in more complicated CS. pic.twitter.com/xBnnhzN40E
— cardio-met (@cardiomet_CE) October 20, 2021
42) Here, 304 AMI pts w/CS & treated w/primary PCI are randomised 1:1 to:
— cardio-met (@cardiomet_CE) October 20, 2021
-IV cangrelor (bolus 30 μg/kg ->infusion 4 μg/kg/min) vs
-oral ticagrelor
Primary clinical endpoint: 30-day MACE (Death/MI/Stroke)
Laboratory endpoint: peri-procedural platelet inhibition (PRU< 50%)
So: pic.twitter.com/NvBqoul5qs
43) That’s it from us. This case of STEMI in shock has taken us on a long ride and there are more data from focused trials to come! For now, I am @aayshacader, I THANK YOU for joining us, & I invite u to go to https://t.co/m3VOGFRbrJ and claim your credit! pic.twitter.com/wh2WkJ54jb
— cardio-met (@cardiomet_CE) October 20, 2021