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[Music] good morning and thank you for providing me an opportunity to be here in this conference cardio the for this part the speaker is dr pk who is a dm and dnp cardiology he is associated with the medical super specialty hospital and ruby hall general hospital kolkata is specialized in interventional cardiology and cardiovascular surgery his medical interests are angioplasty angiography atherectomy [Music] so he's a truly international cardiologist and he's going to talk on a very peculiar subject patient which has been given here is a 60 year male who is diabetic hypertensive strong family history has a seven stroke four year back completely recovered and now one day before has an infidel mi and have put three stands he is coming for follow up apart from his medical optimization of therapy and lifestyle what can be added over and above the spring whether or not and for that matter dr hazra is going to speak for 10 minutes about the addition of river examine 2.5 milligram vid over and above the spring and other medical optimization therapy for the patient thank you very much over to you sir thank you also ah sorry for the next uh this uh blue corner is our famous dr hemang bakshi he's a very eminent cardiologist from the city of ahmedabad interventional cardiologist and director of sims hospital postgraduate in medicine from the my own bj medical college from where i belong and gold medal in the dm cardiology is authored many research papers and had extensive experience in the field of clinical traditional cardiology he performed more than 5000 btcs and is one of the pioneer in the primary angiogram in gujarat he received the prestigious fellowship of american college of cardiology and fellowship of european society of cardiology so truly a very experienced person and after the dr hajra plus medical optimization therapy for the same patient which we have already talked thank you very much over to dr azra thank you please allow me to share my screen please allow me to share my screen yes sir your screen is already there okay so thank you dr sharma for inviting me and case is already been shown there now you know this cad is just like having a pimple on this beautiful face so your screen is not visible uh it is a whiteboard please uh open your presentation first and then state now can you see yes yes now it is visible okay so thank you dr cad and many other cerebrovascular disease or peripheral vascular disease i'll come back to cda this is just like a pimple on your friends and it can be treated untreated there's necrotic rupture stress food many things are important so lifestyle is very very important to keep your simple uh pimple uh not disgracing your face so you have a stain and you just cover one people if you have blue stain you cover two pimples and if you have three stone you cover three pimples and these people are basic information for our case to understand what i am going to say if you take this case 60 years there are some trials which fits into it the red red color tells you that it doesn't fit into that trial they take more than 65 years encompass they take enrichment criterias if somebody is less than 65 years diabetic control mi hypertension is not there in compostal stroke is not there in pegasus if somebody has a stroke so this patient does not fit into pegasus star pegasus talks about multivascularity compass talks about polyvascularity the strong feminist is not there in both the trials this liberty we are not there secret is missing which is a very important component of com composter with this i mean i propose a score for this patient for my convenience like chad vs core ccf a is more than 65 in non-asian and more than 55 in asian so he gets one point diabetes and if he has got stroke and multivascular coronary artery disease he gets four points and if he has got four points is a solid case for dpi not dapt or sapt now i have very very low threshold to prescribe bpi in these patients very rarely patient will escape my prescription or dpis typically this patient now if you talk about a b c d e f g h i j of polypharmacy or monotherapy you have many drugs which can brings your death down nine percent two percent an outlier is here that it reduces death and stroke by 42 percent and close by another molecule we just finished talking about 32 percent plus increasing stroke with empathy frozen 18 percent so what are these molecules these are basically dpi in buggy closings out here now this is basically evidence based whether lipid lowering whether blood pressure lowering everything is important and what is more important to choose the right drug for the right patient in right time for the right period of time and if you continue to choose the best drug like dpi weight the average 72.5 milligram plus small dose of aspirin but perhaps on the top of your lifestyle modification you can make it better you can make make it 82 percent relativities reduction that is amazing unfortunately you do not have any marker for uh these riverox 7 plus aspirin combinations like ldl so this biomarker or the bio targets are absent that is only drawback but you have the same drawbacks for your dapt or sap reserves so both are at same level of lack of evidence and this data came from not from randomized clinical trial it came from a registry the dapt and this dpi is very important initially we thought that the apt is more important now we think that dpi or thrombin with the most powerful platelet agonist it's very important after few days of angioplasty 12 months of acute corneal syndrome when you treat a patient we do not treat only the the molecule or the cellular level you also treat the society as large so in the society if you give this molecule you'll prevent many debilitating stroke amputation so on and so forth and this is the history and the history is very beautiful of dapt but history just begun with the trial which has been stopped prematurely he cannot name any sdapd trial sapd trial any combination of antiplatelet trial because of its overwhelming benefit like jupiter spring paradigm gradients feminine dapper ckd is controlled you have only one trial on this antiplatelet antithrombotic that is composter and the dap dapd duration again topsy turvy course so there is a confusion but now we are moving towards shorter dapt initially we had clinical inertia we had some kind of myths some kind of stigma because we had some we have done some historical mistakes like having bms having cipher like stain having texas like stand and when we used to put the stand we used to prolong the apt because of incomplete job a wrong judgement now it has been much more prudent to do complex pci with imaging so it is just like i could not fix the brake therefore i made the horn louder so this horn louder means longer dpt definitely this imaging helps you see better now many people still live in medical tribalism that means they still believe nothing can replace the apt we are a special group needs preservations we are indispensable we are the gospel truth deep it is only true that is not true anymore because you have evidence from compass trial that it reduces cb mortality all cost mortality so that is beyond any doubt whatever the number the number is excellent and beautiful you have only one molecule in 2022 which has shown its beauty whether it's vein this artery or this pulmonary whether it is brain other atrial fibrillation so it's beautiful molecule so now you have a freedom of choice to choose between two dapt or two antiplatelet aspirin plastic gloss in this case you have aspirin now the other one is also another anti-platelet that is clopidogrel prosciutto but you should go for the best that is pepsi or the ribosome if you have more risk factor you gain more and this benefit is usually disappears recognized versus plasma from three mistral at 6.5 years so beyond this period what takes the upper hand is the dpi and we bleed more and we bleed more on the apt so yeast bleeds more than waste on dpt than dpi at the cost of ischemic risk but the ischemics is very small so i would prescribe dapd many patients face this kind of rapid cv sometimes like appendicitis fracture this emergency situation is much easier to handle than dapd now this is trial which is controversial if you bring down your ldl which we very often do bring it down to 40 or 50 55 if you bring it down with thicker drawer you bleed more if you bring it down to 54 perhaps that is the threshold so you bleed more or trickle down with lipid lowering again this is new information japan they do not use titanglore at all they believe floppy diagram so after they mastered that you moving we're moving toward sapt a single-handedly but if you move if you really want to go fast go alone if you want to go further go together with a little boy a little elephant that is rivaroxaban 2.5 milligram these benefits accumulate over time so we give go longer with this molecule so if i want to finish here for those who believe no explanation is necessary for those who do not know expression is possible i will finish with the short story that world champion dealer s final the evs four girls were favorite and they were one person who 100 meter sprint another one 200 meter sprint so odd was in favor of us 43.59 and 44 but at the end if you see that the blue represents french moving to the baton ultimately the french team wins this relay race but how they want look at her legs is as good as us but look at the change or hand over a button better and the strong command so handover was excellent and beautiful you can argue with the future but for me then you perhaps going for path of immortality so dpi is the only way to go thank you for your kind attention thank you sir uh dr himanbakshi okay yes good morning everybody can am i audible yes but screen screen yeah most lights dr your slides are not visible yeah now yes you are not seeing emma yeah all right start the video so uh thank you organizers cardicon dr sharma for inviting me for this uh a nice debate and uh thanks doc dr hazra for uh i mean uh i mean attractive talk uh now i will discuss my viewpoint on pica great on 60 milligram video with aspirin in this patient just a minute so we know the patients right he's having multiple risk factors has got stroke four years back and he has got multivessel pci and has got imperial mi before one year uh i would have loved to have some further details like egfr of these patients uh what are the ongoing medications does patients have pid and what was the type of the stroke the patient suffered from but anyhow let us discuss the signs i don't have those beautiful pictures but i will stick on to the signs whether there is a need for long-term ischemic protection post mi and how does the long long term ischemic risk rise and if you look at the uh various uh data that each registry shows that there is in patients with i mean in the patients with ischemic events there is i mean quite high long-term risk of ischemic events further ischemic events over 48 months and this is the apollo registry which showed that approximately 20 percent of the patients had the risk of second subsequent mi following one year of myocardial infarctions over next three years uh and this is the uh plasma of the pegasus trial where it was uh observed that the mains incidence was 15 percent up to 72 months after uh per myocardial infarctions and these risks last and continues up to seven years in this improv it trial what about the patients with complex pci patients we know that patients who had undergone complex pci they have got significant high rates of mace mi and i mean strength thrombosis over a period of time so these are the patients which have got a significant residual risk and we need to do something and we have this dft study which showed that uh the the the reduction in the ischemic events was significant when this cleopatra clopidogrel was given for long term up to 36 months in these patients and this is the results of the i mean this is the pegasus tv uh study which studied patients more than 50 years with history of spontaneous mi one to three years prior to enrollment and at least one additional risk factors that is age more than 65 diabetes second triomine multivessel cad and chronic end stage renal disease they were included and they were given long-term picadolol and the study we already know the results that the long-term 60 milligram tick credor has got significant benefit over aspirin alone when it is given beyond 12 months and this reduction in mace is complemented by individual end point reductions that is cv that mi and stroke significantly as you can see over here uh major reading was expectedly high uh in uh 60 milligram arm but the fatal bleed or ich were similar between these two uh arms and uh most important thing to remember is that the greatest benefit of this tricogradol is when it is initiated within two years of prior mi so earlier initiation optical gets benefit uh as you can see the pegasus tme 54 analysis you can see that irreversible harm that is cv death mi stroke ich and fatal bidding was significant 40 14 reversal is there and that is why the guidelines have accommodated this recommendation and you you can see that accha as well as esc has given class 2b indications in patients who are medically managed and not having high bleeding risk uh for giving ticagrelor or or antiplatelet uh secondary agents more than 12 months up to 36 months after uh mi as you can see in uh esc guidelines tikka granola is the clear leaf preferred over clopidogrel not in the acc aha guideline while in patients who is undergoing pci and they are not having high bleeding days again it is a class to be indications that this uh ticagrelor should be given beyond 12 months in these patients now uh we have to identify the high risk patients who can get benefit the most uh with this long-term dual antiplatelet agents and these are the patients who are having more than two risk factors and they benefit the most and our patient has more than two risk factors he is diabetic and he is he is having multi-vessel uh disease so he is definitely going to benefit uh more when this ticagrelo long term is given and as you can see these are the risk factors patients which are having this they get the greatest benefit and if you have more than one two risk factors then the benefit is definitely going to be high but at the same time you have to exclude the patients who has got high bleeding risk so this is a very good algorithm so step one is you assess the bleeding grace the patients who has got prior hospitalization for bleeding or patient who has got low baseline hemoglobin they should be excluded then you find out the risk factors if the patient has got more than two respecters then they are going to benefit the most as far as deep i mean you can see the maze is a maximum benefit in patients who has got multiple risk factors cv death all those days again best in patients who has got multi-purpose factors and our patient fits depth in this criteria because you can see this that patient has got multi vessel disease he has got diabetes we don't know about the renal uh impairment uh patient is definitely not having i mean i mean multiple prior mi but with these two risk factors history of mi before one month ticagrelor 60 milligram vid three years uh post uh i mean up to three years it leads to significant 34 percent risk reduction in seven mortality and 21 percent distribution in cv mi or stroke now coming to the the the the other molecule that dr hazra discussed uh rewarding subman you can see the comparison of the trial that 100 of the patients with pegasus db 54 had prior mi and median of 1.7 years since their qualifying mi while compass trial had 62 patients with prior mi and mean of 7.1 years from their index events though our patients resembles more with this pkf's biggest estimate 54 uh trial patients at the same time the maze was definitely reduced with uh uh reversible compass trial but you can see mi was slightly high although not statistically significant but stroke was uh significantly increased in these patients and our patient also had a stroke so we should be careful while giving this uh river examining this patient and this is the slide showing efficacy versus i mean major breeding with the river exhibit bleeding is definitely high but more worrisome is that in this study it was shown that breeding was associated with increased risk of cancer we don't know i mean it may not be positive it may be just a coincidence but you can see that number of cancers new cancers proportion diagnosed after breeding was much higher whether it is gi cancer or genetic unitary cancer and the cancer was diagnosed early that is within six months after the bleeding as you can see from this slide and the author's conclusion was that that among compass patients with vascular disease on long term antithrombotic therapy more than one in five new diagnosis of cancers are preceded by bleeding and gi bleeding and geo bleeding are powerful predictors of new gi and gu cancer diagnosis respectively more than 75 percent of these cancers are diagnosed within six months of the breeding event and this did this should be kept in mind and you should be careful for that so in summary epidemiological studies confirmed that our patients with prior mi remain at high risk of major adversity events up to five years after the event the apt with dicaprio 60 milligram per asa reduces this risk but at the expense of increased major but not fatal or interacting with bleeding and a simple patient selection algorithm in which patients predictors of high bleeding risk that is anemia or prior history of major breeding are first excluded and then the remaining patients are stratified according to the number of ischemic risk factors may be useful to identify patients more likely to derive greater benefit from treatment with ticagrelor 60 milligram per thank you very much thank you dr emma now the house is open for discussion if there are any questions from anyone i think uh i would not a question but just making the thing more simpler that is the cornerstone of the treatment which antiplatelet enhanced now adding the something which is going to affect the population cascade that is whether it is going to benefit it is a very attractive hypothesis but as dr aman bhaktiv already in his lecture said that there is increased during risk naturally because you are going to block the platelet and coagulation cascade both and every bleeding risk is within few months is going to be diagnosed as the malignancy so that is i think is again a matter of concern but i think there are more light should be thrown on this aspect if anyone else can do that yeah i think the bleeding he has rightly mentioned that goes in favor of bpi regime rather than going in favor of dapt is sometimes a blessing in these guys if you if somebody is on dpi as has rightly mentioned you pick up more gi cancer or your urological cancer bladder cancer earlier because you'll be putting them on cystoscopy upper jail scoopy so if you pick them up early so it's a kind of blessing in disguise and second somebody who is living in a rural area a rural area and he has a hematuria and on the telephone if you ask you doc i am having hemoch they are bleeding i am on dpi one person another person is dapd if you ask them to stop dpi because of short acting the baroque sermon he is actually protected from the very next day but on the other hand which is precalcular regime that he is not protected for five to six seven days as i mentioned during emergency surgery somebody who is on dpi is much simpler to handle than the dapt cabgor i mean appendix or a ruptured gallbladder so these people are much more safe to deal with with surgical emergency so definitely i'll go for dpi but uh basically basically if you talk about this particular patient patient has got multi-vessel stenting patient has got suffered inferior or mi before one year patient is having multiple risk factors so in this particular patient dr hazra is right that reward support is a good molecule but i would i mean i would be hesitant in giving these patients who has got multiple stents uh to give uh i mean i would prefer to give antiplatelets rather than anticoagulants over a longer period of time and your exception i would say that it's a good molecule but in patients uh with chronic coronary syndrome uh i mean uh or patients who are low risk for post pci in those patients it's a good option but in this particular patient i should we should be uh giving a uh i think fantastic data is driven primarily by patients who have had mi which this case has stroke is something which is significantly reduced by rivaroxaban not so much for him uh by chicago uh that was the other tilting point for the era rock saban and mi was the tilting point for taika grove that's why the whole debate and we do get scenarios like this but now we have evidences emerging even for acute stroke for daika grilo but remember there the dosaging is 90 not 60. so that was the another highlight to bring out uh i think both of the speakers did fantastic uh deliberation on this but i would just ask both of you if this patient had suppose another episode of tia what would be your next strategy if he had a tia what would happen to the two therapies that you're giving first dr hajj and then dr bakshi i think we were nicely mentioned the stroke is the outlier pegasus did not have any stroke patient so he doesn't fit into vegas like basically if i'm if i want to um go i mean choose my death i'll never choose stroke i never choose dialysis and never choose cancer rather i want to die from a good micro infarction which is painless there so stroke is devastating not only for yourself but the whole society and the family sometimes so stroke is important if you have a stroke you have 80 percent reduction in the nano the stroke so i if somebody was on dpi i wish he is taking the meds in the chance of getting another ti is very low if he gets a tia you have to investigate against the characters and the other sources of embolism and you can go for ticagrelor for the for the drip period and later on when the things are getting nicer you can go back to dpi thank you i think uh dr rajiv agarwal wanted to make a comment i think yes i'm sorry thank you so uh i'll say two simple things in just less than a minute once the atherosclerosis moves out of you out of the heart you tilt towards dpi if it is confined to heart it is simple dapd but if you look at the compass intervention data about thousand patients that also favors in pci multiversal disease confined to heart a dpi that is another subgroup analysis of course it is not a double-blind placebo-controlled trial so i'll say i'll go more for dpi than dabt there's no mortality reduction with the abt that is one thing which attracts me right so it's like a pimple you get pimple on your face people on your back people in your neck so it's not restricted to always in the heart thank you sir
High Risk CAD - Long Term Strategy
Dr. P. K. Hazra: RIVAROXABAN 2.5 mg BD with aspirin
Dr. Hemang Baxi: TICAGRELOR 60 mg BD with aspirin
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