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CC Nov 2016 Dual Anti-Platelet Therapy (DAPT)

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echoecho's version from 2016-11-24 16:05

Section

Question Answer
*** Unless there are clear contraindications, patients with CAD should be treated with what medication?ASA 81 mg (range 75-100 mg) for secondary prevention of ischemic events
What does DAPT involve?involves addition of a second platelet agent, generally a P2Y(12) platelet receptor inhibitor.
List three commonly used P2Y(12) inhibitors?1) clopidogrel (Plavix) 2) prasugrel (Effient), 3) ticagrelor (Brilinta)
Compared to ASA mono therapy, what does DAPT do?DAPT reduces ischemic cardiac events after PCI with stunting OR recent ACS that includes ST-elevation MI (STEMI) and non-ST elevation MI (NSTEMI)
Prolonged DAPT is associated with what?increased bleeding complications
***For patients undergoing elective PCI and stunting for stable ischemic heart disease (SIHD) (i.e. No hx NSTEMI or STEMI in the last 12 months), the minimum duration of DAPT is what for bare metal stents and what for drug-eluding stents?1) one month 2) 6 months
A longer duration of therapy at be reasonable in what type of patient?Patient at low risk of bleeding
Although prior guidelines recommended a minimum of ____ months of DAPT after drug-eluding stent placement, the guideline committee noted what regarding second-generation drug-eluding stents vs. first generation drug-eluding stents?1) 12 months 2) second generation have a lower rate of stent thrombosis than first generation drug eluding stents
First generation stents are rarely used in current practice, name examples of first generation stents?1) sirolimus-eluding 2) paclitaxel-eluding stents
Non-inferiority trials show comparable rates of ischemic complications with ____ months and ____ months of DAPT in low risk patients (without hx of NSTEMI or STEMI) who have a second generation drug-eluding stent? In such patients it may be reasonable to shorten the duration of DAPT to _____ months in the event of serious bleeding or the need for oral anticoagulation?1) six; twelve months 2) 3 months
*** DAPT should be continue for a minimum of ____ months after NSTEMI or STEMI, regardless of whether a revascularization procedure was performed?12
In patients who experience a serious bleeding event while on therapy, or who acquire risk factors of bleeding (such as an independent indication for oral anticoagulation), it may be reasonable to discontinue DAPT after ____ months?6
In patients with stable ischemic heart disease (no STEMI or NSTEMI within the last 12 months), who undergo CABG, the guidelines indicate that ____ months of DAPT may be reasonable to maintain graft potency?12 months
Is DAPT indicated in patients with ischemic coronary disease WITHOUT ACS or revascularization hx?no
Why is Clopidogrel the only P2Y(12) inhibitor the only recommended agent for patients with stable ischemic heart disease (no hx of NSTEMI or STEMI in the last 12 months) and PCI BUT no ACS hx?because it is the only P2Y(12) inhibitor studied in these types of patients
Compare the three P2Y(12) inhibitors as to lower rates of ischemic events? Compare as to higher rates of bleeding?1) prasugrel (Effient) and ticagrelor (Brilinta) are associated with lower rates of ischemic events 2) prasugrel (Effient) is associated with higher rates of bleeding
Which P2Y(12) inhibitor is preferred over clopidogrel (Plavix) in patients with ACS or STEMI who are treated with PCI? Which one is preferred over clopidogrel (Plavix) in ACS and STEMI patients with not a high risk of bleeding?1) ticagrelor (Brilinta) 2) prasugrel (Effient)
Prasugrel (Effient) is contraindicated in patients with what medical conditions? Why?1) CVA, TIA 2) prasugrel is associated with net harm, including an increase in intracranial hemorrhage
Several studies comparing 12. Months of DAPT with "extended" therapy (an additional 18-36 months of therapy), what are the findings of these studies?1) extended therapy appears to provide an ABSOLUTE risk reduction of about 1-2 % in ischemic events (stent thrombosis, MI), with an absolute RISK increase of 1% in bleeding complications 2) this close benefits/harm balance suggests that treatment decisions should be individualized
List the clinical variables and score points (total score > 2 points predicts a favorable risk/benefit ratio for extended DAPT)?age (> 75 years = - 2 points); age 65-74 years (-1 points); age <65 (0 points); cigarette smoking (+ 1 point); diabetes mellitus (+ 1 point); MI at presentation (+ 1 point); previous PCI or MI (+ 1 point); paclitazel eluting stent (+ 1 point); stent diameter <3 mm (+ 1 point), CHF or LVEJ < 30% (+ 2 points); stenting of vein graft (+ 2 points)
List the guidelines of use of PPIs with DAPT?1) PPIs should be prescribed for patients on DAPT who have a hx of GI bleeding 2) PPI use is reasonable in patients who have other risk factors for GI bleeding, although routine PPI with DAPT is not recommended
*** Some patient with indications for DAPT have a separate indication for an oral anticoagulation (patients with recent stent placement and atrial fibrillation). Patients on this so called "triple therapy" are at very high risk of bleeding complications, what are the recommendations in these patients?1) duration of triple therapy should be as short as possible; in patients at very high risk, dual therapy with an anticoagulant and clopidogrel (without ASA) should be considered. Clopidogrel is the preferred P2Y(12) inhibitor and target INR should be at the low end of the therapeutic range (2.0 - 2.5)
*** SUMMARY = For patients undergoing elective PCI and stenting for stable ischemic heart disease (no hx of STEMI or STEMI in the last 12 months), the minimum duration of DAPT for bare metal stents is ____months and ____ months for drug-eluting stents?one month; 6 months
*** SUMMARY = In patients with stable ischemic heart disease (no STEMI or NSTEMI in the last 12 months) who undergo CABG, the guidelines indicate that ___ months of DAPT may be reasonable to maintain graft patency?12 months
*** SUMMARY = DAPT should be continued for a minimum of ____ months after a NSTEMI or STEMI, regardless of whether a revascularization procedure was performed?12 months
*** SUMMARY = The _______ score may help to determine which patients will benefit from extended anti-platelet therapy?DAPT score
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