Future Directions in
Treatment of STEMI
Vietnam Heart Association Meeting
Danang October 12, 2014
Thach Nguyen MD FACC FSCAI
Director of Cardiology
St Mary Medical Center, Hobart IN


1. P2Y12 inhibitor for CAD


• Jernberg T, Payne CD, Winters KJ, Darstein C,
Brandt JT, Jakubowski JA, Naganuma H,
Siegbahn A, Wallentin L. Prasugrel achieves
greater inhibition of platelet aggregation and a
lower rate of non-responders compared with
clopidogrel in aspirin-treated patients with stable
coronary artery disease. Eur Heart J
2006;27:1166–1173.


• Gurbel PA, Bliden KP, Butler K, Tantry US, Gesheff
T,Wei C, Teng R, Antonino MJ, Patil SB, Karunakaran
A, Kereiakes DJ, Parris C, Purdy D, Wilson V, Ledley
GS, Storey RF. Randomized double-blind assessment of
the ONSET and OFFSET of the antiplatelet effects of
ticagrelor versus clopidogrel in patients with stable
coronary artery disease: theONSET/OFFSET study.
Circulation 2009;120:2577–2585



ESC 2012 STEMI Guidelines



2. Anticoagulant for PCI



Guidelines regarding bivalirudin
for primary PCI
Source
2012 ESC
(Eur Heart J
2012;33,2569-2619)

2013 ACC/AHA
(JACC 2013;61,e78-140)

2013 ACC/AHA
(JACC 2013;61,e78-140)

Recommendation

Class

Level

Bivalirudin (with use of GP2b/3a blocker restricted to
bailout) is recommended over unfractionated heparin

–
–

–

Heparin 70 U/kg
Bivalirudin 0.75 mg/kg bolus, 1.75 mg/kg/hr
infusion
Selective (bailout) abciximab

• Primary outcome at 28 days


HEAT PPCI
Procedural characteristics
• Radial access 80%
• P2Y12
–
–
–

Clopidogrel 11%
Prasugrel 27%
Ticagrelor 62%

• Abxicimab 14%
• PCI performed 82%


Event curve shows first event experienced

0.7

Stent Thrombosis

3.4

0.9

0.001

Major bleed

3.5

3.1

0.59


Cheaper,
Easy to use
Comparable efficacy


BRIGHT Trial
Bivalirudin vs Heparin and
Heparin + Tirofiban in Primary PCI

• Multicenter randomized controlled trial
(China)

Door to device time 66-70 min
Clopidogrel 100%
PCI performed 98%
Stent 96%
Han TCT 2014


BRIGHT
Primary and principal secondary endpoints at
30 days

Han TCT 2014



3. Anticoagulant after PCI



• In the CURE trial, the residual risk for death, MI, or
stroke after 12 months of treatment with clopidogrel
together with aspirin was approximately 10%. In the
TRITON and PLATO trials, with new and more
potent antiplatelet agents combined with aspirin,
there was the same residual risk. As the mechanism
of ACS is due to superimposed thrombus, the
hypothesis is that anticoagulants might improve the
CV outcomes in patients with a recent ACS. In
early 2000, this hypothesis was tested in the WARIS
trial with warfarin. (REF: Hurlen NEJM 2002; 347: