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Ticagrelor as Long-Term Secondary Prevention in Patients with PAD and Prior MI

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In this new paper in JACC, Marc P. Bonaca, MD, of the TIMI Study Group, discusses new data from PEGASUS-TIMI 54. The CSWN interview was conducted in at ACC.16 in Chicago.

Here at acc 16 in chicago of course investigators are presenting two separate sub analysis of pegasus timmy 54 which investigated the long-term use of takara lure in patients with a history of myocardial infarction and at least one additional risk factor for thrombotic cardiovascular events the first sub analysis included patients with peripheral artery disease and the

Second patients with diabetes so to do this i’m talking with dr. mark maracana who is an md and he’s with of course the timmy study group and from bremen women’s hospital in boston where your lead investigator for the pid some analysis of pegasus and your part of the vascular medical center there at brigham this is really an important group of people some really high

Risk folks but let’s talk first about why did you focus on this population of patients with pid so we know that patients with prefer artery disease are at a heightened risk of ischemic risk so myocardial infarction stroke cardiovascular death and we know that patients with prior mi and pa d so called poly vascular disease are at even higher risk so this is a very

High risk population as you noted in the introduction pegasus timmy 54 overall showed that take advil or reduced cardiovascular risk over the long term there was some increase in bleeding and so we felt this was a cohort that might derive particularly robust benefit from more intensive antithrombotic strategy as long-term secondary prevention so how many patients

Were analyzed so just over a thousand patients were in the pa d sub group and they were analyzed as the primary group for this and it’s like over a three year period right yeah so all the patients were randomized one two three years after mi this 1100 patients or so had symptomatic peripheral artery disease or abnormal abi and they were followed for three years of

Therapy and so what did you find so first we found that when you look at patients that have peripheral artery disease and prior mi vs patients with prior am i alone those that have pa dr much higher risk of major adverse cardiovascular events the event rated three years was twenty percent meaning one in five patients had cv death mi or stroke vs a much lower rate

In patients without peripheral artery disease and when you look at the individual events there a higher risk of cardiovascular death all cause mortality and of course limb event so first we saw that it was a much higher risk population than those without pa d and that that relationship remained even after we adjust it for all of the imbalances at baseline so that

They have more diabetes more smoking even after you adjust for that they’re at higher risk is that appreciative among the cardiovascular community yeah i think that people understand that patients with peripheral artery disease are at higher risk for ischemic events not necessarily beyond prior myocardial infarction and so i think this does add to that and that

Poly vascular disease as others have described is a much higher risk population and then the second part of the analysis of course was looking at how they responded to therapy for the second analysis you did a sub analysis of almost 1,600 patients with a prior mi and diabetes yes so what went on in that study yeah so similar to peripheral artery disease diabetes

Indicated a higher risk population within the trial cohort and so diabetes much like pa d more aggressive athletic phenotype worse outcomes and then both of these populations by nature of their higher risk both translated into a greater absolute risk reduction with tacabro war for the pa depopulation the absolute risk reduction was more than four percent over three

Years for a number needed a treat of about 25 and so very attractive and in the 60 milligram dose that was that is approved for use actually had a very attractive efficacy profile with reductions in cv death and all cause more so i think these really underscore that higher risk populations derive greater benefit saw the same thing in pa d a greater absolute risk

I’m sorry in diabetes greater absolute risk reduction and similar to non-diabetic patients there was an increase in timmy major bleeding with chuck hagel or yes but it did not offset the advantages yeah and so he raised a very important point i think one of the themes that this conference has been the struggle that we’re all grappling with in terms of applying

The d apt and the pegasus timmy 54 data in clinical practice is a very broad populations coronary disease getting stents or prior myocardial infarction and people have said well in order to take on this bleeding risk there needs to be a robust risk reduction needs to be offset and so part of these subgroup analyses is to illustrate to the clinical community that

There are some groups of patients they’re very high risk that that derive a great absolute risk reduction and i think we’ve seen that now at the pa depopulation and the diabetes population and i think importantly the most sophisticated way to sort of integrate all these factors is to risk scores and so ba ba and the dap team have put out a risk score for post pci

Patients and aaron burr hula and dave moro have put one out for long term secondary prevention i think these type of subgroup analyses help inform the need for those type of risk scores or sort of add all these factors together and say this patient is going to get a robust benefit that’s worth the risk i with the right before the acc 16 meeting the acc put out an

Update to the eyelines yes it’s focusing on depth use yes and have you had a chance to look at those yet they said does it help well i think it it really i think stresses the need for individual individualization of care there is no one-size-fits-all and i think that comes out loud and clear in the guidelines and is appropriate they do talk about things like the

Dap risk score and and there are other risk scores that have been published the one by aaron burr hula that i mentioned and i think to me that’s what the takeaway is that we can’t we can’t make this an algorithmic decision we have to really select patients based on their risk they’re tolerability or their ability to tolerate drug and they’re bleeding profile and

Hopefully these sub analyses this pa d sub group where you know one in five have a bad event in three years and you can have greater than four percent absolute risk reduction i think that may be meaningful to clinicians as a subgroup that derives particular benefit well i advise that you go check out on line at acc or because they do have a whole section that’s

Kind of focused on this update of the guidelines thanks to the depth study and some other analyses like this one that has come along recently so for cardio source world news i’m executive editor rick would like you

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Ticagrelor as Long-Term Secondary Prevention in Patients with PAD and Prior MI By CSWNews