Longterm Management After

Percutaneous Coronary Intervention

Risk Factor Modification

Novi Anggriyani, MD. FIHA

 Background

US data show :
Over the last decade, the growth rate for PCI centers is 1.5x that of
the population growth, while MI prevalence is decreasing
The number of PCI centers has grown 21.2% over the last 8 years,
with 39% of all hospitals having interventional cardiology
capabilities
MI prevalence rates have decreased from 4.0% to 3.7%.

Langabeer, J.R,et al.J Am Heart Assoc. 2013;2:e000370

 Number of PCI Center and PCI rates

Number of PCI Center-US(2003-2011)

Langabeer, J.R,et al.J Am Heart Assoc. 2013;2:e000370

PCI Rates-UK(2013)

National Audit of Percutaneous Coronary Interventions.2013

 Stents

Nearly eliminated abrupt vessel closure

Significantly reduced stenosis
Reduced urgent CABG
Type of stent
Bare Metal Stent
Drug Eluting Stent
First generation (sirolimus,paclitaxel)
Second generation (zerolimus,everolimus)
Secondary and Long-Term Prevention: Post-PCI

Short-term Prevention
Acute
24 hours incidence:
stent
0.6%
thrombosis

Sub-acute Days to weeks

stent thrombosis incidence: <5%

Late stent Up to 12 months

Long-term Prevention

restenosis incidence: 15%

Major adverse cardiac First year incidence:

events ~20%

Other atherothrombotic
Life-long
events (all arterial beds)
Stent Thrombosis
What should we do?
 Risk Factor

Risk Factor Modification and

Secondary Prevention !!
Risk Factor Modification & Secondary Prevention
ABCDEs

Antiplatelets & Anticoagulation

Blood Pressure Management
Cholesterol & Cessation of Smoking
Diet (Diabetes)
Education & Exercise
 Dual Anti-Platelet Therapy (DAPT)

2016 ACC/AHA Guideline Focused Update on Duration

of Dual Antiplatelet Therapy in Patients With Coronary
Artery Disease
 DAPT in patient with SIHD treated with PCI

CoR LoE Recommendations

In patients with SIHD treated with DAPT after BMS implantation, P2Y12
I A inhibitor therapy with clopidogrel should be given for a minimum of 1
month
In patients with SIHD treated with DAPT after DES implantation, P2Y12 inhibitor
I B-RSR therapy with clopidogrel should be given for at least 6 months
In patients treated with DAPT, the recommended daily dose of aspirin is 81 mg
I B-NR (range, 75 mg to 100 mg)
In patients with SIHD treated with DAPT after BMS or DES implantation who have
tolerated DAPT without a bleeding complication and who are not at high bleeding
IIb ASR risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use),
continuation of DAPT with clopidogrel for longer than 1 month in patients treated
with BMS or longer than 6 months in patients treated with DES may be reasonable
In patients with SIHD treated with DAPT after DES implantation who develop a
high risk of bleeding (e.g., treatment with oral anticoagulant therapy), are at high
risk of severe bleeding complication (e.g., major intracranial surgery), or develop
IIb C-LD significant overt bleeding,discontinuation of P2Y12 inhibitor therapy after 3
months may be reasonable
 DAPT in patient with ACS treated with PCI

CoR LoE Recommendations

In patients with ACS (NSTE-ACS or STEMI) treated with DAPT
after BMS or DES implantation, P2Y12 inhibitor therapy
I B-R (clopidogrel,prasugrel, or ticagrelor) should be given for at least
12 months

In patients treated with DAPT, the recommended daily dose of aspirin is

I B-NR 81 mg (range, 75 mg to 100 mg)

In patients with ACS (NSTE-ACS or STEMI) treated with DAPT after

IIa B-NR coronary stent implantation, it is reasonable to use ticagrelor in
preference to clopidogrel for maintenance P2Y12 inhibitor therapy

In patients with ACS (NSTE-ACS or STEMI) treated with DAPT after

coronary stent implantation who are not at high risk for bleeding
IIa B-R complications and who do not have a history of stroke or TIA, it is
reasonable to choose prasugrel over clopidogrel for maintenance P2Y12
inhibitor therapy
 In patients with ACS (NSTE-ACS or STEMI) treated with coronary stent
implantation who have tolerated DAPT without a bleeding complication
and who are not at high bleeding risk (e.g., prior bleeding on DAPT,
IIb ASR coagulopathy, oral anticoagulant use), continuation of DAPT
(clopidogrel,prasugrel, or ticagrelor) for longer than 12 months may be
reasonable
In patients with ACS treated with DAPT after DES implantation who
develop a high risk of bleeding (e.g., treatment with oral anticoagulant
therapy), are at high risk of severe bleeding complication (e.g., major
IIb C-LD intracranial surgery), or develop significant overt bleeding,
discontinuation of P2Y12 inhibitor therapy after 6 months may
bereasonable
Prasugrel should not be administered to patients with a prior history of
III B-R stroke or TIA
Levine GN,et al.J Am Coll Cardiol.2016 PCI

SIHD ACS

DES BMS

0 mo Class I:
At least 1 mo
Class IIb: High (Clopidogrel)
Discontinua bleeding Class I:
tion after risk or
3 mo 3 mo may significant
At least 6 mo
Class I:
(Clopidogrel)
be overt At least 12
reasonable bleeding mo
(Clopidogrel,
prasugrel,tic High
Class IIb:
agrelor) bleeding Discontinu
risk or
6 mo significa
ation after
6 mo may
No high bleeding risk or significant nt be
overt bleeding on DAPT overt reasonable
bleeding
Class IIb: Class IIb:
>6 mo may be >1 mo may be
reasonable reasonable
12 mo
 Main Results of the CURE Trial

Placebo+ Clopidogrel
CV Death,MI or Stroke Aspirin +Aspirin (N Relative Risk Reduction P value
(N 6303) 6259)
CV death,MI or stroke 9.3% 11.4% 20% 0.00009
CV death 5.1% 5.5% 7%
Stroke 1.2% 1.4% 14%
MI 6.7% 5.2% 23% <0.001
STEMI (Q wave MI) 3.1% 1.9% 40% <0.001
Refractory ischemia 2.0% 1.4% 32% 0.007
Severe ischemia 3.8% 2.8% 26% 0.003
Recurrent angina 22.9% 20.9% 9% 0.01
Thrombolityc therapy 2.0% 1.1% 43% <0.001
Congestive Heart Failure with 4.4% 3.7% 18% 0.026
radiologic evidance
The Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators.N Engl J Med
2001; 345:494-502
Main Results of the PCI-CURE Study
 Discontinuation of DAPT as predictor of stent thrombosis
HR=19.2
(5.6-65.5)
25

HR=13.7 HR=13.8
(4.0-46.7) (8.8-21.6)
20

15

OR=4.8 HR=4.6
10 (2.0-11.1) (1.4-15.35)

Park,et al Kuchulakanti, Airoldi,et al Lasala,et al Van Werkum,

et al et al
Park,D,et al.Am J Cardiol.2006;98:352-356
Kuchulakanti PK,et al.Circulation.2006;113:1108-1113
Airoldi F,et al.Circulation.2007;116:745-754
Lasala JM,et al.Circ Cardiovasc Interv.2009;2:285-283
Van Werkum JW,et al.J Am Coll Cardiol.2009;53:1399-1409
 Methods to Prevent Premature Discontinuation

Discuss with patient BEFORE stenting

Educate patients post-procedure
Instruct patients to contact their physician prior to
discontinue any medication
Control to physician
 Risk Factor Modification ABCDEs

Antiplatelets & Anticoagulation

Blood Pressure Management
Cholesterol & Cessation of Smoking
Diet (Diabetes)
Education & Exercise
 Blood Pressure Control Recommendations

ACCF/AHA Guideline

Goal: <140/90 mm Hg
I IIa IIb III
As tolerated, add blood pressure medication, treating initially with beta blockers
and/or ACE inhibitors with addition of other drugs such as thiazides as needed to
achieve goal blood pressure.

I IIa IIb III

Initiate or maintain lifestyle modification: weight control, increased physical
activity, alcohol moderation, sodium reduction, and increased consumption of
fresh fruits vegetables and low fat dairy products

Smith, S.Circulation. 2011;124:2458-2473

 ESC/EACTS Guideline

I IIa IIb III

A DBP goal of <90 mmHg is recommended in all patients. In patients with

diabetes a DBP goal <85 mmHg is recommended

I IIa IIb III

ACE inhibitors are recommended in all patients with CAD if there is
presence of other conditions (e.g. heart failure, hypertension or
diabetes). ARBs are an alternative, if ACE inhibitors are not tolerated
I IIa IIb III
A systolic blood pressure goal <140 mmHg should be considered in
patients with CAD.

ESC/EACTS Guideline on Myocardial Revascularization. 2014

JNC 8 Hypertension Guideline Algorithm
 Beta Blockers
I IIa IIb III
b-Blocker therapy should be used in all patients with left ventricular systolic dysfunction
(ejection fraction 40%) with heart failure or prior myocardial infarction, unless
contraindicated.
I IIa IIb III
b-Blocker therapy should be started and continued for 3 years in all patients with normal
left ventricular function who have had myocardial infarction or ACS

I IIa IIb III

It is reasonable to continue b-blockers beyond 3 years as chronic therapy in all patients with
normal left ventricular function who have had myocardial infarction or ACS

I IIa IIb III

It is reasonable to give b-blocker therapy in patients with left ventricular systolic
dysfunction (ejection fraction 40%) without heart failure or prior myocardial infarction.
I IIa IIb III
b-Blockers may be considered as chronic therapy for all other patients with coronary or
other vascular disease.
Smith, S.Circulation. 2011;124:2458-2473
 ACE Inhibitor/ARB

I IIa IIb III ACE Inhibitors

ACE inhibitors should be started and continued indefinitely in all patients with left ventricular
ejection fraction 40% and in those with hypertension, diabetes, or chronic kidney disease,
unless contraindicated
I IIa IIb III

It is reasonable to use ACE inhibitors in all other patients

I IIa IIb III

ARB
The use of ARBs is recommended in patients who have heart failure or who have had a
myocardial infarction with left ventricular ejection fraction 40% and who are ACE-inhibitor
intolerant
I IIa IIb III
It is reasonable to use ARBs in other patients who are ACE-inhibitor intolerant

I IIa IIb III

The use of ARBs in combination with an ACE inhibitor is not well established
in those with systolic heart failure.
Smith, S.Circulation. 2011;124:2458-2473
 ACE inhibitors inhibit the
enzyme necessary for the
conversion of A-I to A-II
A-II receptor blockers ->
block angiotensin II
from receptors in blood
vessels, adrenals, and
all other tissues.
 Lifestyle Modifications for BP Control

Approximate SBP Reduction

Modification Recommendation
Range

Weight reduction Maintain normal body weight (BMI=18.5-24.9) 5-20 mmHg/10 kg weight lost

Adopt DASH eating Diet rich in fruits, vegetables, low fat dairy and
8-14 mmHg
plan reduced in fat

Restrict sodium
< 2.4 grams of sodium per day 2-8 mmHg
intake

Regular aerobic exercise for at least 30

Physical activity 4-9 mmHg
minutes on most days of the week

BMI=Body mass index, SBP=Systolic blood pressure

Chobanian AV et al. JAMA. 2003;289:2560-2572
 Risk Factor Modification ABCDEs

Antiplatelets & Anticoagulation

Blood Pressure Management
Cholesterol & Cessation of Smoking
Diet (Diabetes)
Education & Exercise
 ESC/EACTS Guideline

Goal LDL < 70 mg/dL

I IIa IIb III
Statin therapy with an LDL-C goal <70 mg/dL (<1.8 mmol/L) is indicated to
start and continue in all patients with CAD after revascularization, unless
contraindicated.

ACCF/AHA Guideline
I IIa IIb III

High-intensity statin therapy should be initiated or continued in

all patients with STEMI and no contraindications to its use
 ACCF/AHA Guideline

I IIa IIb III

In addition to therapeutic lifestyle changes, statin therapy should be prescribed
in the absence of contraindications or documented adverse effects.
I IIa IIb III
1. A lipid profile in all patients should be established, and for hospitalized patients,
lipid-lowering therapy as recommended below should be initiated before
discharge
2. Lifestyle modifications including daily physical activity and weight management
are strongly recommended for all patients
3. Dietary therapy for all patients should include reduced intake of saturated fats
(to ,7% of total calories), trans fatty acids (to ,1% of total calories), and
cholesterol (to ,200 mg/d)

Smith, S.Circulation. 2011;124:2458-2473

Therapies to Lower LDL-C
Class Drug(s)
Atorvastatin
Fluvastatin
3-Hydroxy-3-Methylglutaryl
Lovastatin
Coenzyme A (HMG-CoA) reductase
Pravastatin
inhibitors [Statins]
Rosuvastatin
Simvastatin

Cholestyramine
Bile acid sequestrants Colesevelam
Colestipol

Cholesterol absorption inhibitor Ezetimibe

Nicotinic acid Niacin
Soluble fiber
Dietary Adjuncts Soy protein
Stanol esters
 The Role of Lipoproteins in Atherogenesis
HDL High plasma Endothelial
LDL injury

LDL Adherence
+ LDL infiltration
VLDL into intima of platelets
LCAT
APO-A1
Release
Oxidative
Liver modification of PDGF
of LDL Other
+ growth
Cholesterol Macrophages factors
excreted Advanced
Foam cells
fibrocalcific
Fatty streak lesion
APO-A1=Apolipoprotein A1, HDL=High density
lipoprotein, LCAT=Lecithin cholesterol acyltransferase,
LDL=Low density lipoprotein, PDGF=Platelet-derived
growth factor, VLDL=Very low density lipoprotein
 Cigarette Smoking Recommendations

Goal: Complete Cessation and No Exposure

to Environmental Tobacco Smoke

I IIa IIb III 1. Every tobacco user should be advised at every visit to quit
2. Patients should be assisted by counseling and by development of a plan for
quitting that may include pharmacotherapy and/or referral to a smoking
cessation program
I IIa IIb III
1. Patients should be asked about tobacco use status at every office visit
2. All patients should be advised at every office visit to avoid exposure to
environmental tobacco smoke at work, home, and public places
I IIa IIb III
1. The tobacco users willingness to quit should be assessed at every
visit.
2. Arrangement for follow up is recommended.
 Risk Factor Modification ABCDEs

Antiplatelets & Anticoagulation

Blood Pressure Management
Cholesterol & Cessation of Smoking
Diet (Diabetes)
Education & Exercise
 ESC/EACTS Guideline

Goal HbA1c < 7.0%

I IIa IIb III
A target for HbA1c of <7.0% is recommended, which is particularly well established
for the prevention of microvascular disease.

ACCF/AHA Guideline
I IIa IIb III
Lifestyle modifications including daily physical activity, weight management, blood
pressure control, and lipid management are recommended for all patients with
diabetes.
I IIa IIb III
Care for diabetes should be coordinated with the patients primary care
physician and/or endocrinologist
I IIa IIb III
Metformin is an effective first-line pharmacotherapy and can be useful
if not contraindicated.
 Risk Factor Modification ABCDEs

Antiplatelets & Anticoagulation

Blood Pressure Management
Cholesterol & Cessation of Smoking
Diet (Diabetes)
Education & Exercise
 ACCF/AHA Guideline

I IIa IIb III 1. All eligible patients with ACS or whose status is immediately post coronary
artery bypass surgery or post-PCI should be referred to a comprehensive
outpatient cardiovascular rehabilitation program either prior to hospital
discharge or during the first follow-up office visit.
2. A home-based cardiac rehabilitation program can be substituted for a
supervised, center-based program for low-risk patients
3. All eligible outpatients with the diagnosis of ACS, coronary artery bypass
surgery or PCI within the past year should be referred to a comprehensive
outpatient cardiovascular rehabilitation program
 Exercise Evidence: Mortality Risk

Observational study of self-reported physical activity in 772 men with

established coronary heart disease

Wannamethee SG et al. Circulation 2000;102:1358-1363

Summary
THANK YOU

Keep your heart healthy