Presentazione di PowerPoint

1
Activated Platelet
Clopidogrel Prasugrel
To neighboring platelet
Gp IIb/IIIa fibrinogen receptor
Thrombin Serotonin Epinephrine Collagen
COX
Activation
?
?
Degranulation
Platelet agonists ADP ATP serotonin calcium magnes
ium
TXA, thromboxane PDGF, platelet-derived growth
factor.
2
Healthy VolunteerCrossover Study
100
N66
80
InterpatientVariability
60
IPA at 24 hours ()
40
InterpatientVariability
20
Clopidogrel Responder
0
Clopidogrel Non-responder
-20
Response to Prasugrel 60 mg
Response to Clopidogrel 300 mg
From Brandt JT AHJ 153 66e9-66e16,2007
3
TRITON Primary EndpointCV Death,MI,Stroke
15

Clopidogrel
12.1(781)
9.9 (643)
10
Primary Endpoint ()
Prasugrel
HR 0.81(0.73-0.90)P0.0004
HR 0.80P0.0003
HR 0.77P0.0001
5
NNT 46
LTFU 14 (0.1)
ITT 13,608
0
0
30
60
90
180
270
360
450
Days
4
TRITON TIMI 8 Bilancio efficacia/sicurezza in
pzlt75 Yrs, 60 kg, e senza pregresso TIA/Stroke
1
6
CV Death / NF MI / NF Stroke
1
4
NNT37
Clopidogrel
11
1
2
Hazard Ratio, 0.75 (95 CI, 0.66-0.84) Plt0.001
1
0
Endpoint ()
8
Prasugrel
8.4
6
Non-CABG TIMI Major Bleeding
Hazard Ratio, 1.240 (95 CI, 0.91-1.69) P0.17
NNH222
4
Prasugrel
1.95
2
Clopidogrel
1.50
0
0
30
90
180
270
360
450
Days
Adapted from Wiviott SD et al NEJM 357 2001,
2007 Presented at TCT 2009, San Francisco, CA
5

• Prasugrel a chi darlo?
• Rischio emorragico
• Comorbidita
• STEMI versus NSTEMI
• Eventi ricorrenti
• Trombosi di stent

6
(No Transcript)
7
TRITON sottogruppo dei pazienti con STEMI
Endpoint di sicurezza
Endpoint di efficacia
8
Wiviott SD, N Engl J Med 2007357(20)2001-15
9
(No Transcript)
10
Distribution of Subjects in the TRITON TIMI 38
Trial
BMS bare metal stent C clopidogrel DES
drug-eluting stent PES paclitaxel eluting
stent PCI percutaneous coronary intervention
P prasugrel SES Sirolimus eluting stent
11
Clinical Events by Stent Type(Any Stent)
Clop ()
Pras ()
12
10
Primary Endpoint (CV death/non-fatal MI/non-fatal
stroke
CV death/non-fatal MI/UTVR
12
10
CV death/non-fatal MI
11
9
CV death
2
2
MI
10
7
UTVR
4
2
Revascularization
6
4
TIMI major bleeding
2
2
Death/non-fatal MI/non-fatal stroke/non-fatal
TIMI major bleed
14
12
0.5
0.6
0.7
0.8
0.9
2.0
Hazard Ratio
Prasugrel better
Clopidogrel better
12
ARC Definite or Probable Stent Thrombosis (day 0
to day 450)
2.5
Clopidogrel
2.35
HR 0.48 (0.36-0.64) Plt0.0001
2.0
1.5
of Subjects
1.13
1.0
Prasugrel
0.5
1 year 1.06 vs. 2.15 HR 0.48 (0.36-0.65)
Plt0.0001
0.0
0
50
100
150
200
250
300
350
400
450
Days
ARC Academic Research Consortium
13
ARC Definite or Probable Early Stent Thrombosis
(030 days) in Patients Receiving DES
2.5
HR 0.29 (0.15-0.56) P0.0001
2.0
Clopidogrel
1.5
of Subjects
1.44
1.0
Prasugrel
0.5
0.42
0.0
0
5
10
15
20
25
30
Days
ARC Academic Research Consortium DES
drug-eluting stent
14
ARC Definite or Probable Late Stent Thrombosis
in Patients Receiving DES
2.5
2.0
HR 0.46 (0.22-0.97) P0.04
1.5
of Subjects
0.91
1.0
Clopidogrel
0.5
Prasugrel
0.42
0.0
30
90
150
210
270
330
390
450
Days
Using landmark analysis for all patients, with
events occurring from 030 days censored from the
analysis
ARC Academic Research Consortium DES
drug-eluting stent