Dr. Threadgill shared two cases that he saw at Coos Bay, our community hospital experience on the Oregon Coast.
Middle aged smoker with a history history of a CABG several years ago and had stopped all medications presents with substernal crushing chest pain while getting out of the shower. EKG revealed ST depressions in the lateral leads. Initial troponin was 0.06 and peaked at 6. He underwent a coronary angiogram which showed
Left main – short, calcified, mid-distal 80% stenosis LAD – mid chronic total occlusion with patent LIMA-LAD and SCG-Diag grafts Circumflex – OM#4 with 90% discrete proximal stenosis RCA - sub-total, discrete stenosis at the bifurcation of the PL and PDA.
We discussed initial management of ACS by reviewing the ACC/AHA 2014 ACS guidelines.
We also discussed the PLATO trial— “Ticagrelor vs Clopidogrel in Patients with ACS”
ACC/AHA 2016 update on dual-antiplatelet therapy:
“In the PLATO (Platelet Inhibition and Patient Outcomes) trial (53), patients with ACS were treated with either medical therapy alone or medical therapy plus PCI. Treatment with ticagrelor 90 mg twice daily, compared with clopidogrel 75 mg once daily, resulted in fewer ischemic complications and stent thromboses but more frequent non–CABG-related bleeding”
Ticagrelor (Brilinta) is superior to clopidogrel, though remains much more expensive
Dr. Shatzel with hematology provided some great data on the benefits of loading with clopidogrel in NSTEMI patients.
He also recommends residents review a review article on “Anticoagulation in the Cardiac Patient: a concise review.” It was written by our own alumni (Elise Larsen, David German) along with Dr. Shatzel and Dr. Deloughery.