The Use Of Dual Anti Platelet Therapy

Coronary artery disease (CAD) is the commonest heart disease in the United States1. Approximately, 29% of patients with Myocardial Infarction ( MI ) present with ST- elevation Myocardial Infarction ( STEMI )2. STEMI is the result of complete occlusion of a major epicardial coronary artery due to thrombus formation. STEMI from a small coronary artery presenting as substantial EKG abnormalities similar to occlusion of a major artery and hemodynamic instability is a rare entity. The epidemiology, typical clinical presentation, outcomes, and optimal management in this group of patients are not sufficiently known.

The clinical practice project I chose to write about and research is dual antiplatelet therapy. Dual antiplatelet therapy is the combination of aspirin and a P2Y12 inhibitor such as Plavix, Effient, or Brillinta after stent placement in patients who have experienced an ischemic event such as a myocardial infarction or stroke (AHA, 2016). I chose this topic because I work on a telemetry unit that cares for patients who have experienced a myocardial infarction and have undergone stent placement. Part of their post-op care is initiation of dual antiplatelet therapy and education regarding its importance. I feel like more educational materials are needed to assist patients and nurses with this education.

The evidence based practice process gives more evidence of young patients with few risk factors and no structural heart defect, the benefits of anticoagulation may be outweighed by the risks of haemorrhage (bleeding). High quality guidelines and the systematic searches used for the topic in this portfolio were beneficial. Use of a rigorous and transparent process in this portfolio for identifying, appraising and adopting/ adapting guidelines are crucial to help for the decision making. A major factor that stops the usage of the new drug is unfortunately, there are no specific antidotes to reverse the coagulant effects of the direct thrombin or factor Xa

Aspirin – this is medication that is used to help prevent inflammation in your body and also helps prevent blood clots. This medication is important to prevent another blockage in your heart that can cause another heart

There are many people that suffer from venous thromboembolism. Venous thromboembolism includes both deep vein thrombosis and pulmonary embolism. This is the third most common cause of vascular death after a myocardial infarction, also known as a heart attack, and stroke. This article examines the possibility of either full or low intensity anticoagulation therapy versus aspirin. This was a randomized study that consisted of 3,396 individuals who have venous thromboembolism. These individuals either received rivaroxaban, which is an anticoagulant, or 100 mg of aspirin once a day. The individuals in this study completed 6-12 months of anticoagulation therapy and were eligible for inclusion in the study if they were 18 years of age or older. The

Clopidogrel is a second-generation thienopyridine antiplatelet agent used in humans and other species including cats to reduce the risk of thromboembolic diseases secondary to cardiovascular diseases and other systemic diseases. Once it’s converted to clopidogrel active metabolite by Cytochrome P450 isoenzymes, clopidogrel irreversibly inhibits one of the platelet ADP receptors leading to an inhibition of platelet activation and aggregation. Several large clinical trials revealed that clopidogrel administration in human patients significantly reduced the platelet activation and aggregation in vivo, and decreased the frequency of developing thromboembolic events (Sabatine MS et al. JAMA 2005, Yusuf S et al. NEJM 2001, Chen ZM et al. Lancet 2005).

The main concerns regarding treating a patient with AF are rhythm control, rate control, and anticoagulation (Zak, 2010). For patient X, he was started on Metoprolol (beta blocker), Amiodarone (anti-dysrhythmic) and Warfarin (anticoagulation). Due to Warfarin’s ability to alter the INR of the blood, it is imperative to monitor the INR frequently to ensure that the level is therapeutic (Shea and Sears, 2008). Patient X had a full time job though making minimum wage. He was unable to take time off of work to get his blood drawn monthly for INR levels at his doctor’s office. This would result in sub therapeutic levels of anticoagulation and therefore noncompliance. He suffered a pulmonary embolus from the sub therapeutic anticoagulation and was hospitalized. After speaking with his cardiologist regarding other means of anticoagulation, the decision was made to change his medication from Warfarin to Pradaxa, an anticoagulant of a different

Atrial fibrillation is the most frequent cardiac arrhythmia. There has always associated risk of clot formation and embolization that can lead to ischemic stroke. A large number of these ischemic events could be prevented by timely anticoagulation. Warfarin has been used for decades for this purpose, but there are many problems for the patients due to warfarin therapy like there is continuous need of INR monitoring, many food and drug interactions of the drug, late onset of action and risk of major bleeding. Anticoagulation with the Novel oral anticoagulants e.g. Dabigatran, rivaroxaban, apixaban, endoxaban led to similar or even lower rates of ischemic stroke and major bleeding compared to an adjusted dose of warfarin (INR 2-3) in patients

A non-ST elevation acute coronary syndrome (NSTE-ACS) is a very common presentation to emergency departments everywhere, as well as primary care practices. Therefore, it is important that all providers be well informed on the effectivity of certain treatment regimens.

Providing care for post percutaneous coronary intervention (PCI) patients has evolved and the guidelines and protocols have been heavily influenced by research and evidence based practice (EBP). Unfortunately, coronary heart disease has become a major issue for the health status of Americans across the lifespan. According to the CDC, “About 610,000 people die of heart disease in the United States (U.S.) every year – that’s 1 in every 4 deaths.” In addition, treating coronary heart disease patients has negatively impacted the economic status of U.S. healthcare. Therefore, to manage

For many year’s patients with atrial fibrillation have been treated with anticoagulants such as Warfarin to prevent strokes and embolisms. Unfortunately, Warfarin must be closely monitored and that is an irritant for some patients. In October 2010, the FDA approved a new generational anticoagulant drug called Dabigatran (Pradaxa). This alternate medication gives patients the benefit of no dietary restrictions since dabigatran is not affected by certain foods. Another benefit of taking dabigatran is a monthly blood test is not required to measure its effectiveness, so for this particular reason many patients switch from taking other anticoagulants to dabigatran (Talati & White, 2011). Since this medication does not require close monitoring, some wonder if is it truly a better option or can more harm than good come from taking it. While the benefits of using dabigatran have shown significant improvement over warfarin, there are still risks associated with using dabigatran.

The period entered for the search was from January 2002 to August 2015. The Search terms were: “dual antiplatelet therapy”, “shortened DAPT”,”, “clopidogrel”, “early discontinuation”, “Drug-eluting stenting in diabetes mellitus AND Dual Antiplatelet Therapy”, “extended DAPT”, “prolonged DAPT”, “gastroenteritis AND clopidogrel”, “Delayed eosinophilic gastroenteritis and gastroenteritis”, “thienopyridine”, “P2Y12”, “premature cessation “drug eluting stents AND diabetes” , “duration of dual antiplatelet therapy”. The search had to be modified to include patient’s co-morbidities, medications and medical condition. The search initially started with optimal duration of dual antiplatelet therapy in patients after drug-eluting stent revascularization, and then the search was broadened to include diabetic patients with drug-eluting stent. Lastly I included gastroenteritis to unearth any relation between clopidogrel and Mrs GL’s hospital admittance.

Clopidogrel can be prescribed prophylactically to high-risk patients or to those who have experienced atherothrombotic events such as strokes, acute coronary syndrome, peripheral arterial diseases or any other thrombi-producing illnesses (Cheek, 2013). Clopidogrel works by inhibiting the binding of adenosine diphosphate to platelet receptors, thus, disrupting the process of platelet formation and preventing platelet aggregation and thrombi formation. However, in order to inhibit the binding of ADP, clopidogrel has to be converted to its active form by the enzyme CYP2C19*1. Unfortunately, some people have lost the ability to produce enzyme CYP2C19*1 and instead produce a variant form known as CYP2C19*2. CYP2C19*2 cannot convert clopidogrel to its active form, making clopidogrel useless in patients who carry gene CYP2C19*2. Providentially, pharmacogenomics can identify variant genes with DNA sequencing prior to prescribing medications in order to assure the effectiveness of pharmacologic therapy. This also helps health care providers to prescribe alternate medications when appropriate.

Acute coronary syndrome encompasses patients diagnosed with unstable angina, non-ST elevation myocardial infarction, and ST-elevation myocardial infarction (Amsterdam et al., 2014). Per the American College of Cardiology (2014), a rapid evaluation to identify life-threatening cardiac conditions is imperative for patients presenting to emergency departments with symptoms of acute coronary syndrome and an electrocardiogram is an essential tool for diagnosis (Amsterdam et al., 2014). Patients with ST-elevation myocardial infarction have a 7.4% increase in risk of mortality with every half-hour that passes before implementing appropriate reperfusion therapy (Omar, Helal, Mangar,

The U.S. Preventative Services Task Force (USPSTF) recommends that men between the age of 45-79 utilize aspirin for the possible advantage of decreasing the risks and probabilities of a myocardial infarction. The risk to benefit ratio of using aspirin is warranted to surpass the risk of gastrointestinal bleeding. The clinical considerations for this particular patient fall under his age and his family history. According to the information known the patient is not diabetic, does not smoke, and exercises frequently with acceptable healthy use of alcohol. Nevertheless, family history is a strong indicator of potential medical issues and the patient has a family history of heart disease. The patient's blood pressure and cholesterol levels are constituents of his health that should also be taken into consideration, but are not outlined for this patient. As indicated by the USPSTF, the number of preventable myocardial infarctions decreases by 3.2 per 1000 men for the age range of this patient. The potential for GI bleeding is 8 out of every 1000 men and 1 out of every 1000 men for hemorrhagic stroke. Do to the patient's age and family history I find