Thread by @cardiomet_CE

#CMGsays: Join here tomorrow for the launch of a new accredited tweetorial on optimal management of diabetic and other high-risk patients with stable CAD, particularly those with previous PCI, to reduce the risk of MI or stroke. Expert faculty is the incomparable @CMichaelGibson

Earn 0.5 CE/CME credits: #physicians, #nurses, #pharmacists! #medtwitter @academiccme #CardioTwitter @MedTweetorials @CardioNerds @SABOURETCardio @DLBHATTMD @gabrielsteg @DrMauricioCohen @cpcannon @DocSavageTJU @djc795 @DFCapodanno @SnayCardsPharmD @beaverspharmd

And you’ll learn how these data should impact your practice:

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 . . .

. . . and this accredited educational activity is intended for healthcare providers and is supported by grants from AstraZeneca, Bayer, Chiesi, and NovoNordisk.

2) Last month you followed an excellent Journal Club tweetorial by @gabrielsteg on #THEMIS and THEMIS-PCI. (If you didn't, go to cardiometabolic-ce.com/plts6 and check it out, and you can still get your CE/#CME credit!) You may recall that . . .

3) . . . Ticagrelor plus aspirin yielded generally consistent and favorable net clinical benefit across the diabetes-related factors in THEMIS-PCI but not in the overall THEMIS population.

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:

5) Pts with both #T2D and #CAD are at high risk for #CV events. If they have had ACS in the past, standard therapy for secondary prevention, independent of presence of #diabetes, includes #DAPT.

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 . . .

7) . . . that DAPT specifically with ticagrelor and low-dose ASA could produce #netclinicalbenefit in patients with (1) T2D, (2) stable #CAD, (3) past #PCI, but no history of MI or stroke. And in fact, the #FDA then added to the indications for ticagrelor . . .

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.

9) So let's see where you are starting here. Which of the following factors has NOT been shown to influence the incidence of major cardiovascular events in response to antihyperglycemic therapy?

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

11) Welcome back to this #tweetorial on #DAPT as potential PRIMARY prevention in selected high-risk cohorts! I am @CMichaelGibson and I am happy you found the ONLY source for serialized accredited tweetorials in #cardiometabolic care! @HeartBobH @GruentzigG @Drroxmehran

12) The answer to yesterday's poll is "extent of glucose control" (doi.org/10.1016/j.jacc…). 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 . . .

13) . . . overall benefit on major CV events, there was a modest reduction in MI (doi.org/10.1007/s00125… and doi.org/10.1016/S0140-…), so it is still a good idea.

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.

15) The efficacy and safety of ticagrelor #DAPT did not, however, differ by baseline antihyperglycemic therapy. including #SGLT2i use, which we know likely brings its own independent CV benefits.

16) In THEMIS-PCI, but not THEMIS, ticagrelor generally produced favorable net clinical benefit across subgroups by diabetes duration, HbA1c, and antihyperglycemic medications.

17) So what do we do with this? Let's start with a graphic that @gabrielsteg used in his #tweetorial, showing the characteristics that identify CAD patients at higher risk of thrombosis/ischemia and at higher risk of bleeding from therapy:

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 . . .

19) . . . and that's consistent with a more aggressive #DAPT strategy as seen in THEMIS-PCI. #Diabetes, polyvascular disease, #CKD, and #heartfailure also increase ischemic risk. So when your patient has markers like these, look in parallel at major factors for bleeding risk.

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.

21) Fortunately, there are many #CAD patients out there who have had PCI, who have diabetes, or who have other high-risk concerns (such as #HF). THEMIS-PCI and the resulting label expansion for ticagrelor suggest that these patients,

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:

23) Mark your answer and return tomorrow for discussion and wrap-up! @CardioNerds @Sglt2inhibitorL @SriPittaMD @BinitaShahMD @HenrytTimothy @ChrisKramerMD @willsuh76 @DrAllenJ @chadialraies @ankeetbhatt @DrLaxmiMehta @datsunian @JenHoCardiology @AmiBhattMD @AdiAJoshi #FOAMed