FARMACOLOGIA ADJUNTA À INTERVENÇÃO CORONÁRIA

PERCUTÂNEAANTIPLAQUETÁRIOS,

ANTITROMBÍNICOS, HIPOLIPEMIANTES

Carlos Augusto Bueno Silva,DrServiço de Hemodinâmica e

Cardiologia Intervencionista do Hospital São João de Deus –

Divinópolis Sem conflito de interesses.

Antiplaquetários

Aspirina

Ticlopidina

Clopidogrel

Prasugrel

Cilostazol

Inibidores 2b3a

Aspirina

Inibição da ativação plaquetária

Eficácia da Aspirina x Dose

CURE – Sangramento maior – Dose de aspirina – 1 ano

Aspirina no IM agudo ISIS-2

ISIS 2 Lancet 1988;2:349-60

Tienopiridínicos

Eficácia da antiagregação plaquetária dupla na redução de eventos coronarianos

pós Stents

Equivalência entre Ticlopidina e Clopidogrel

Dose de ataque de 300mg x placebo

Momento ideal – dose 300mg

Dose de 600 mg é superior ?

ARMYDA - 2

ARMYDA-2 Eventos Hemorrágicos

The ISAR-REACT trial evaluated the efficacy of abciximab in 2159 patients undergoing elective percutaneous coronary intervention (PCI) . All patients were pretreated with 600 mg of clopidogrel at least two hours before PCI. When the study subjects were grouped into four subsets based upon duration of clopidogrel pretreatment (2 to 3 hours, 3 to 6 hours, 6 to 12 hours, and >12 hours), there was no significant difference among the four groups in the incidence of death, MI, or urgent revascularization at 30 days or in the rate of major bleeding.

OASIS 7

).CONCLUSIONS: Single doses of clopidogrel higher than 600 mg are not associated with an additional significant suppression of platelet function because of limited clopidogrel absorption.

Absorption, metabolization, and antiplatelet effects of 300-, 600-, and 900-mg loading doses of clopidogrel: results of the ISAR-CHOICE (Intracoronary Stenting and Antithrombotic Regimen: Choose Between 3 High Oral Doses for Immediate Clopidogrel Effect) Trial.von Beckerath N, Taubert D, Pogatsa-Murray G, Schömig E, Kastrati A, Schömig ACirculation. 2005;112(19):2946.

The ARMYDA-4 RELOAD study involved 503 patients already taking chronic clopidogrel who required PCI. They were randomized to a 600-mg clopidogrel loading dose four to eight hours before PCI or placebo. The primary end point was death, MI, or target vessel revascularization at 30 days. In the overall population, this was slightly reduced in the loading-dose group but not significantly so. But those patients with ACS (about 40% of the trial population) did show a better outcome when given the additional loading dose. There was no excess bleeding in the reload arm (6% in both groups).

Balanço entre eficácia e segurança

Diabéticos ( n= 3.146 )

Trombose de Stent

Subgrupos com risco de sangramento

Inibidores GP2b3a

Redução de Morte, IM, nova RM, eventos combinados – 30 dias

Redução de morte, IM, Nova RM, eventos combinados – 6 meses

GP2b3a – Benefício em pctes de maior risco

Cilostazol – Efeitos farmacológicos

Antitrombínicos

Heparina não fracionada

Heparina de baixo peso molecular

Inibidores diretos da trombina

Fondaparinux

Heparina Não fracionada

HNF – Vantagens x Desvantagens

Enoxaparian x HNFMorte ou IM em 30 dias

Enoxaparina em ICP trials

Bivalirudina

Bivalirudina não inferior a HNF/IGP2b3a

Fondaparinux OASIS 5 - Resultados

CSA de alto risco ( VS enoxaparina)Similar eficácia, menor sangramentoNecessidade de HNF suplementear para ICP

Obrigado!