ACS 2* prevention trials

PEGASUS TIMI 54

P: MI 1-3y prior, everyone on low dose ASA

I/C: placebo, ticagrelor 60mg BID, ticagrelor 90mg BID

O: CV death, MI, stroke

results: outcomes reduced by 15% in both with higher bleed with higher dose

bottom line: use ticagrelor 60mg BID

DAPT trial

P: stent with DES after 12m thienopyridine (clopi or prasu) on ASA

I: extra 18m DAPT (total 30m)

C: placebo 18m

O: stent thrombosis, death, MI/stroke beyond 12m, bleeding

results: all cause mortality and bleed risk increased in prolonged treatment, made risk calculator

bottom line: longer DAPT has CV benefits but higher bleed risk and may increase mortality

What did the “Risk of Bleeding on Triple Antithrombotic Therapy After Percutaneous Coronary Intervention/Stenting: A Systematic Review and Meta-analysis” show regarding tripe therapy?

increases bleed risk

WOEST trial

P: oral anticoag (minimum 1y) + PCI using warfarin

I: clopidogrel alone (double therapy)

C: clopidogrel + ASA 80-100mg (triple therapy)

O: any bleed within 1y of PCI, assessed with intention to treat

results: small benefit with triple therapy but higher bleed risk

bottom line:

ISAR TRIPLE therapy

P: DES with ASA + OAC (80% afib)

I: 6wk triple therapy

C: 6m triple therapy

O: 1* endpoints, 2* endpoints, bleeding

results: no diff between 1* vs 2* endpoints after 9m, more bleed with longer therapy

bottom line: use triple therapy for shorter period

PIONEER AF PCI

P: nonvalvular afib with PCI + stent (DAPT and DOAC indicated)

I/C: rivarox 15mg daily + clopidogrel 75, rivarox 2.5mg BID, triple therapy with warfarin

O: bleeding, death from CV, MI, stroke

results: riva + clopidogrel seemed to be safest, outcomes similar in all three groups

bottom line:

AFIRE trial

P: afib with PCI or CABG >1y before or angiography confirmed CAD

I: combo riva + single antiplatelet

C: monotherapy with riva

O: stroke, embolism, MI, UA requiring revasc, death from any cause

results: stopped early since monotherapy noninferior to combo for outcomes and superior for safety

bottom line:

REDUCE AMI trial

P: STEMI/NSTEMI + PCI with LVEF >50% and no other indication for B blocker

I: long term B blocker (metoprolol or bisoprolol)

C: no B blocker

O: 1* and 2* outcomes

results: no difference between B blocker vs none

ABYSS trial (non inferiority design)

P: stable with prior MI and chronic B blocker but no HF or reduced LVEF

I: d/c B blocker

C: continue B blocker

O: 1* or 2* outcomes

results: d/c b blocker was shown inferior

bottom line: continue B blockers

EPHESUS trial

P: 3-14d after ACS, LVEF <40%, HF, DM (no need HF symptoms)

I: eplerenone 25mg

C: placebo

O: 1* endpoint all cause mortality and CV hospital/death

results: reduced mortality and hospitalization death in 16m

bottom line: use eplerenone (or spironolactone; RALES trial) in LVEF <40% with HF and/or DM

ELIXA trial medication and outcome

lixisenatide did not reduce CV outcomes in T2DM with recent ACS

LEADER trial medication and outcome

liraglutide reduced CV death/MI/stroke in T2DM and high risk CV patients

SUSTAIN 6 trial medication and outcome

semaglutide reduced MACE (stroke) in T2DM

HARMONY outcomes trial medication and outcome

albiglutide reduced MACE (MI) in T2DM with CV disease

REWIND trial medication and outcome

dulaglutide moderately reduced MACE in T2DM with previous CV event or risk factors

SURPASS CVOT trial medications and outcomes

tirzepatide non inferior to dulaglutide for reducing MACE

All of the GLP1RA trials show that they are beneficial for

BMI > 30 and T2DM with either high risk of CV events or previous CVD

SELECT trial

P: overweight/obese + established CVD, no DM

I: semaglutide 2.4mg

C: placebo

O: composite CV death, nonfatal MI/stroke (MACE)

results: reduced CV outcomes

bottom line: can give GLP1RA to those without DM for CV benefits

CLEAR SYNGERY trial

P: STEMI/NSTEMI referred for PCI

I: colchicine 0.5mg BID + spironolactone 25mg

C: placebo

O: time to CV death, recurrent MI, stroke

results: no reduction in MACE at 3y

bottom line: colchicine has no benefit in STEMI/NSTEMI