Earn 0.5 CE/CME credits: #physicians, #nurses, #pharmacists! #medtwitter @academiccme #CardioTwitter @MedTweetorials @CardioNerds @SABOURETCardio @DLBHATTMD @gabrielsteg @DrMauricioCohen @cpcannon @DocSavageTJU @djc795 @DFCapodanno @SnayCardsPharmD @beaverspharmd
— cardio-met (@cardiomet_CE) July 12, 2021
1) Welcome to a tweetorial on #DAPT as it applies to optimal management of high-risk patients with stable CAD–#ACS or #stroke waiting to happen. Accredited for 0.5h by @academiccme: #physicians, #nurses, #pharmacists! I am @CMichaelGibson . . . pic.twitter.com/yXD7fEghei
— cardio-met (@cardiomet_CE) July 13, 2021
2) Last month you followed an excellent Journal Club tweetorial by @gabrielsteg on #THEMIS and THEMIS-PCI. (If you didn’t, go to https://t.co/YKB2fsUdLT and check it out, and you can still get your CE/#CME credit!) You may recall that . . .
— cardio-met (@cardiomet_CE) July 13, 2021
4) In this #tweetorial, we will look more closely at those “diabetes-related factors” and how they helped identify patients at risk for adverse ischemic outcomes, as they may also apply to other high-risk CAD patients who do NOT have #diabetes. Here’s that graphic we promised: pic.twitter.com/gzrDj429vf
— cardio-met (@cardiomet_CE) July 13, 2021
6) Prior to #THEMIS, it was unclear whether high-risk pts who had NOT had an event might actually receive safe and effective PRIMARY prevention with #DAPT. It turns out that #THEMIS and the pre-specified THEMIS-PCI together suggested . . .
— cardio-met (@cardiomet_CE) July 13, 2021
8) . . . the reduction in risk of a FIRST #MI or #stroke even if they DID NOT have T2D. Health Canada and #EMA expanded the ticagrelor label more in line with THEMIS-PCI, but the excitement is that for the first time we have #DAPT approved as primary prevention in ANY setting.
— cardio-met (@cardiomet_CE) July 13, 2021
10) Mark your answer and return tomorrow for more on #DAPT in primary prevention! Come back, #FOAMed @PharmacyUpdates @DocSavageTJU @GreggWStone @DLBHATTMD @DrMauricioCohen @SVRaoMD @SCAI @DFCapodanno @cpgale3 @AtulPathak31 @fjpinto1960 @djc795 @fischman_david @DavidLBrownMD
— cardio-met (@cardiomet_CE) July 13, 2021
12) The answer to yesterday’s poll is “extent of glucose control” (https://t.co/FLoJm1sTVs). While meta-analyses of major trials investigating the potential benefit of glucose control on CV outcomes have revealed that although intensive glucose control had no . . .
— cardio-met (@cardiomet_CE) July 14, 2021
14) In THEMIS, MACE incidence did increase with duration of diabetes duration HbA1c, but major bleeding event rate (overall: 1.6%) did not vary by either and was increased similarly by ticagrelor across all subgroups in both THEMIS and THEMIS-PCI.
— cardio-met (@cardiomet_CE) July 14, 2021
16) In THEMIS-PCI, but not THEMIS, ticagrelor generally produced favorable net clinical benefit across subgroups by diabetes duration, HbA1c, and antihyperglycemic medications.
— cardio-met (@cardiomet_CE) July 14, 2021
18) You see there that there are multiple risk factors for #thrombosis that arise from prior #PCI: complexity, # stents, #lesions, L main stenting, etc. These characteristics indubitably arise from severity of #CAD . . .
— cardio-met (@cardiomet_CE) July 14, 2021
20) Alas, CKD is on this list too! At least DM isn’t. For obvious reason, any bleeding proclivity (whether past bad bleed, liver insufficiency, etc) is worrisome, as is baseline #anemia, which suggests there may be chronic ongoing subclinical blood loss that #DAPT might worsen.
— cardio-met (@cardiomet_CE) July 14, 2021
22) if without those major bleed concerns, would benefit from extended #DAPT. So let’s consider a case: 70M, with known CAD and elective PCI last year (and completed 12 months DAPT), as T2D on an #SGLT2i, is in your office. He had no bleeding while on ticagrelor DAPT. Would you:
— cardio-met (@cardiomet_CE) July 14, 2021
24) #CMGsays: Welcome back! We’re glad you found our innovative, serialized, accredited #tweetorials. Nods to @ShahzebKhanMD @mmamas1973 @DocSavageTJU @JJheart_doc @docsaw @maor_elad @bcostelloMD @josephahill @KAlexanderMD @CianPMcCarthy @hvanspall @aayshacader @mirvatalasnag 🫀
— cardio-met (@cardiomet_CE) July 15, 2021
26) But what about switching from DAPT to “DPI”: “dual-pathway inhibition,” with a DOAC+ASA. Rivaroxaban is the best-studied DOAC in this potential space. Problem 1: data gap–there are no head-to-head studies between DAPT and DPI in this setting!
— cardio-met (@cardiomet_CE) July 15, 2021
28) DPI compared with ASA monotherapy produced consistent reductions in MACE and mortality but with increased major bleeding with or without previous PCI. Among those with previous PCI 1 year and beyond, the effects on MACE/mortality were consistent no matter time since last PCI.
— cardio-met (@cardiomet_CE) July 15, 2021
30) There are of course no randomized comparisons of DAPT vs DPI, but for pts like the one described here (#DM and a history of PCI who has tolerated antiplatelet therapy, has high ischemic risk, and low bleeding risk) long-term DAPT with ticagrelor+ASA should be considered.
— cardio-met (@cardiomet_CE) July 15, 2021
32) In that regard, please also see our #tweetorial by @JoshuaBeckmanMD at https://t.co/GZZvQOSs30. It’s still available there for CE/#CME credit!
— cardio-met (@cardiomet_CE) July 15, 2021
34) . . . therapy of any kind. For a patient without an extracardiac reason to switch to DPI, who has continued ischemic risk and has tolerated a year of DAPT, there is as yet no compelling reason not to continue DAPT.
— cardio-met (@cardiomet_CE) July 15, 2021
35) That’s it! You made it! Free CE/#CME! #Physicians, #nurses, #pharmacists: go to https://t.co/MOJAgDwjdZ and claim your credit! I am @CMichaelGibson. Follow us for more tweetorials! #Medtwitter #MedEd @MedTweetorials #CardioTwitter #FOAMed #pharmacisttwitter @CardioNerds
— cardio-met (@cardiomet_CE) July 15, 2021