Author + information
- Brian J. Potter,
- Alexandra Bastiany,
- Fady El-Turaby,
- Alexandre Angers-Goulet,
- Alexis Matteau,
- Samer Mansour and
- Benoit Daneault
Background: Antithrombotic management of STEMI patients with apical dysfunction is controversial. Clopidogrel-based triple antithrombotic therapy (TATT) may be associated with increased bleeding, while ticagrelor-based dual antiplatelet therapy (DAPT) may not adequately protect against cardio-embolic stroke in this population.
Methods: We undertook a dual-center retrospective study of anterior STEMI patients with apical dysfunction treated with primary PCI between 2013 and 2015 (CHUM & CHUS, Québec, Canada). Patients with prior MI or an established indication for or a contraindication to anticoagulation (OAC) were excluded. CHUM patients with apical dysfunction are frequently treated with TATT, whereas the CHUS has favored ticagrelor-based DAPT since 2013. As STEMI management is otherwise similar at both institutions, the situation is analogous to a “natural randomization” based on geography. The primary composite outcome consisted of death, MI, stroke, revascularization, and BARC 3 or 5 bleeding at 4 months. Crude rates are compared using the Fisher Exact test. Multivariable regression, including propensity adjustment is planned.
Results: We identified 193 cases (74 CHUM; 119 CHUS) with a mean age of 64±12yrs, 73% men and similar baseline characteristics. Procedural success was achieved in 96% and 74% received DES. There was no difference in post-procedure LVEF (39±10% vs 37±9%) or the number of dysfunctional apical segments (median 4). 42% of CHUM patients received OAC (30 warfarin, 1 DOAC) vs 6% at the CHUS (all warfarin; p<0.0001). Follow-up was available for 82%. The primary outcome occurred in 6% (CHUM) vs. none (CHUS; p<0.05), driven by revascularisation. There were no stroke events in either group. Follow-up echocardiograms were available in 43%. 1 CHUS (DAPT) patient developed LV thrombus vs. none at the CHUM.
Conclusions: This exploratory analysis does not support foregoing the benefits of a ticagrelor-based regimen for patients with apical dysfunction following anterior STEMI treated with primary PCI provided close surveillance for development of LV thrombus. A pragmatic randomized trial is warranted to provide a definitive answer to this clinical conundrum.
Poster Hall, Hall C
Sunday, March 19, 2017, 9:45 a.m.-10:30 a.m.
Session Title: Antiplatelet and Antithrombotic Agents in Ischemic Heart Disease
Abstract Category: 3. Acute and Stable Ischemic Heart Disease: Therapy
Presentation Number: 1296-306
- 2017 American College of Cardiology Foundation