So, the patient is diagnosed unfortunately
with ST elevation myocardial infarction.
And while he is in the hospital,
he gets good evidence-based treatment,
gets a percutaneous intervention and,
lo and behold,
they put in two coronary stents.
All of the following medication
should be initiated at discharge except for
remember, this is an except question.
So, everything except,
A, aspirin, clopidogrel or both;
B, a beta blocker;
C, a diuretic;
or D, a statin.
Which do you think should
not be initiated in this patient?
The other drugs are
more or less necessary.
And let’s go through them.
So, aspirin is standard
Certainly should be included for patients with a history of
symptomatic cardiovascular disease or any cardiovascular event.
There is not a difference in efficacy.
81 mg to 325 mg.
But do realize the higher
you increase your dose of aspirin,
the higher risk of hemorrhage,
and we’re talking about a drug that
patients are going to be taking over years.
So, it doesn't seem like just
one aspirin a day should promote
a greater rate risk of particularly
but it does over time.
Clopidogrel is often
employed after stent placement.
And particularly for patients with stroke,
it's slightly superior to
aspirin preventing recurrent strokes.
So, if a patient just
has a history of stroke,
I'll prefer them on a
clopidogrel versus aspirin.
And the combination of aspirin
and clopidogrel is frequently used
and has been associated with improved
effects after stent placement.
Usually that's for
approximately one year.
However, do understand,
at the same time,
that using two antiplatelet agents together
is associated with a higher risk for bleeding.
So, that's part of the balance.
It may be why it’s not a
great idea to continue patients
forever on both drugs because
they will have higher risk of bleeding.
In terms of other drugs that are recommended for
stable atherosclerotic cardiovascular disease,
One of the questions
that comes up is, well,
what about tolerability if
I'm using high-intensity statins.
There really isn't a strong difference
in terms of discontinuation rates
of moderate verse high-intensity statins,
so go for the high-intensity statins.
Your patients will have a reduced
risk of other cardiovascular events
if you can get them
on a high-intensity statin.
Beta blockers as well
should be universal.
So, it’s a first line anti-hypertension
agent among these patients
and a significant reduction in mortality.
The main side effect is bradycardia,
and so that’s something to watch out for
and you might need to titrate your dose,
but most patients tolerate
beta blockers very well.
And if it’s beta-1 selective,
you can even use it in patients
with asthma and COPD,
although with some caution.
Whereas an ACE inhibitor or
an angiotensin receptor blocker,
ACEI or ARB, are
second line for hypertension
and they probably are also associated
with some benefit in these patients
with cardiovascular disease
beyond their blood pressure.
Nitrates are really a backup as
an anti-anginal beta blocker,
so are your number one
anti-anginal drug because they,
one, are effective at treating angina,
but secondarily they promote
better mortality effects versus nitrates.
But for patients with breakthrough type angina,
nitrates can be effective as well.
So, that's really what I want to describe today
with regard to existing cardiovascular disease.
I think the main take-home
points for your patients
for your exam are
maintaining that stable of drugs.
We’re talking about three
or four agents for all patients
who’ve had a history of either
cardiac revascularization procedures
or some kind of cardiovascular event.
So, those really should
be lifelong treatments.
So, think about them and
providing them in the long term
and make sure patients are
thinking about them as well
and they’re enlisted and
empowered in their plan of care.