2. Deborah B. Diercks, MD, MSc, FACEP
Presenting Faculty:
Deborah B. Diercks, MD, MSc, FACEP
Professor and Vice Chair of Research
Department of Emergency Medicine
University of California, Davis Medical Center
Sacramento, CA
Dr. Diercks has disclosed that she is a consultant for LG, Mylan, and Novartis. She has also received grant/research support from Alere, Beckman Coulter, Cardioventis, Radiometer, and Radnor Registry.

3. Glenn N. Levine, MD, FACC, FAHA
Presenting Faculty:
Glenn N. Levine, MD, FACC, FAHA
Professor of Medicine
Baylor College of Medicine
Director, Cardiac Care Unit
Michael E. DeBakey Medical Center
Houston, TX
Dr. Levine has no financial relationships to disclose relating to the content of this activity.

4. Charles Victor Pollack, Jr., MA, MD
Presenting Faculty:
Charles Victor Pollack, Jr., MA, MD
FACEP, FAAEM
Professor of Emergency Medicine
Perelman School of Medicine
Chair, Department of Emergency Medicine
Pennsylvania Hospital
University of Pennsylvania
Philadelphia, PA
Dr. Pollack has disclosed that he is a consultant for Boehringer-Ingelheim, Bristol-Myers Squibb, Daiichi-Sankyo, Janssen, and Pfizer. He also receives grant/research support from Luitpold.

5. Tomas Villanueva, DO, MBA, FACPE, SFHM
Presenting Faculty:
Tomas Villanueva, DO, MBA, FACPE, SFHM
Clinical Assistant Professor of Medicine
College of Osteopathic Medicine
Nova Southeastern University
Medical Director, Hospital Medicine Program
Baptist Health System of Miami
Miami, FL
Dr. Villanueva has disclosed that he is a consulting editor for Hospital Medicine Program Management and a reviewer for Hospital Medicine. He is also on the speakers’ bureaus for American Regent, AstraZeneca, Forest, Novo Nordisk, and Pfizer.

6. Pre-test

7. 67 year old man with history of DM and GI bleed six months ago is admitted with NSTE-ACS. Initial ECG showed anterolateral ST depressions and troponin levels rose to 1.3. He undergoes stenting of the LAD with a drug-eluting stent (DES). He is discharged to your care for further management.

8. What is the most appropriate daily dose of aspirin to treat him with long-term?
81 mg QD
325 mg (enteric coated) QD
325 mg BID (to better prevent stent thrombosis)
It doesn’t matter
NO correct answer shown in pre-test
Countdown 10

9. It depends on which P2Y12 inhibitor he was placed on
How long should his P2Y12 inhibitor therapy (clopidogrel, ticagrelor, or prasugrel) be continued?
One month
3-6 months
At least 12 months
It depends on which P2Y12 inhibitor he was placed on
No correct answer shown in pre-test
Countdown 10

10. Should the patient be placed on a PPI?
It depends
Yes No
Maybe
No correct answer shown in pre-test
Countdown 10

11. Pathophysiology of Plaque Rupture and Acute Coronary Syndromes

12. Coronary Atherosclerotic Plaque
Coronary artery smooth muscle thickening
Foam cells accumulate in smooth muscle
Core of extracellular lipid accumulates

13. Ruptured Vulnerable Plaque with Thrombus Formation
Fibrous
Cap
Thrombus
Plaque Core

14. Plaque Rupture with Coronary Thrombus
This film demonstrates the occurrence of microembolism. While it is apparent that there is a tight stenosis in this artery (LAD), it is also apparent that the thrombotic material that breaks off and embolizes downstream can cause microvascular occlusion, leading to myonecrosis (evidenced by elevated troponin or CK-MB).

15. Platelet Aggregation
Scanning electron microscope photographs showing platelet adhesion and activation (left photo) and early platelet aggregation (right photo)

16. Platelet Cascade in ACS
Adhesion 1
Platelets
Lipid
Core
Collagen
GP la/lla Bind
von Willebrand
Factor/GP lb Bind
Activation 2
Thrombin
ADP
5 HT
TXA2
Aggregation 3
Fibrinogen
Activated
GP llb/llla
Platelet Plug 4
Schafer AI. Am J Med

17. Mortality in the Global Registry of Acute Coronary Events (GRACE)16 12 8 4
% Mortality
Days
STEMI
Mortality from
D/C to six months
STEMI – 4.8%
NSTEMI – 6.2%
Unstable – 3.6%
NSTEMI UA
N=43,810
Fox KA, et al. BMJ. 2006;
Goldberg RJ, et al. Am J Cardiol

18. Aspirin for ACS and Secondary Prevention

20. Aspirin in Acute Coronary Syndromes (ACS)
Unstable Angina
Acute MI
P<.0001
Death or MI
P=.001
Reocclusion
P=.012 MI
P<.001
Vascular Death 20 30 4 15
17.1
25.0
3.3
11.8 15 3
9.4* 20 10
1.9*
Patients (%) 10 2
11.0*
6.5* 10 5 5 1
Placebo
ASA
Placebo
ASA
Placebo
ASA
Placebo
ASA
N= ,587 8,600 8,587 8,600
MI=myocardial infarction
ASA=acetylsalicylic acid
RISC=Research on Instability in Coronary Artery Disease
RISC Group. Lancet. 1990;
Roux S, et al. J Am Coll Cardiol. 1992; ISIS-2. Lancet

21. Chronic ASA Doses and Vascular Events
in High Risk Patients
Antithrombotic Trialists Collaboration. Br Med J

22. Relationship Between Major Bleeding and ASA Dose in ACS Patients
Post-hoc Analysis from CURE
ASA + Placebo
ASA + Clopidogrel
4.9%
5.0
3.7%
4.0
3.4%
3.0%
Incidence of Major Bleeding (%)
2.8%
3.0
1.9%
2.0
1.0
≤100 mg
(N=5,320)
101–199 mg
(N=3,109)
≥200 mg
(N=4,110)
ASA dose (range mg)
Peters RJ, et al. Circulation

23. Aspirin Dosing After ACS/PCI: Current ACCF/AHA Recommendations
UA/NSTEMI (2011 Focused Update):1
mg indefinitely
STEMI (2004 Guideline):2
Secondary Prevention (2011 Update):3
PCI (2011 Guideline):4
Aspirin indefinitely (class I; LOE A)
Reasonable to use 81 mg/day in preference to higher maintenance doses (class IIa; LOE B)
1Wright RS, et al. Circulation. 2011;
2Antman EM, et al. J Am Coll Cardiol. 2004;
3Smith S, et al. J Am Coll Cardiol. 2011;
4Levine GN. J Am Coll Cardiol

24. Clopidogrel After NSTE-ACS

25. CURE Trial: Primary Composite Endpoint (MI/CVA/CV Death)
at 12 Months in Patients with NSTE-ACS
11.4%
Placebo + Aspirin
20% RRR
P=.00009 14 12
9.3% 10
% With Event 8
Clopidogrel + Aspirin 6 4 2 3 6 9 12
Follow-up (Months)
Yusuf S, et al. N Engl J Med

26. Clopidogrel For Primary and Secondary Prevention

27. Final visit (Fixed study end date)
CHARISMA Trial Design (Clopidogrel in Addition to Aspirin in Patients Without Recent ACS)
Clopidogrel 75 mg/day
(N=7,802)
Patients age ≥45 years at high risk of atherothrombotic events*
Low dose ASA mg/day R
Double-blind treatment up to 1040 primary efficacy events (CV death, MI or CVA)
(N=15,603)
Low dose ASA mg/day
Placebo 1 tablet/day (N=7,801)
CHARISMA was a multicenter, multinational, randomized, two-parallel group, double-blind trial of clopidogrel versus placebo
A total of 15, 603 patients with documented atherothrombosis (symptomatic) or multiple risk factors (asymptomatic patients) were randomized to clopidogrel (75 mg per day) or placebo in a double-blind manner, both in addition to background therapy including low-does ASA ( mg/day, the exact dose left to the discretion of the individual treating physician), and followed for a median of 28 months. 2
The randomization was centralized using an IVRS1
CHARISMA was an event-driven trial, meaning that it was planned to end after at least 1,040 blinded, primary events had accrued 2
Since 1,040 primary efficacy events had been reached, the fixed study end date was 29 August
Final visits occurred within the month following the fixed study end date1
During the trial each patient had follow-up visits scheduled at 1 month, 3 months, 6 months, 12 months and every 6 months thereafter until a common study end date 2
All patients were followed from randomization until study end date, with the last patient followed for at least 3 months1
Reference
Bhatt DL, Topol, EJ, et al. Am Heart J 2004; 148: 263–268.
*Documented CAD, CVD, symptomatic PAD or >=2 CRF
1-month
visit
3-month
visit
Visits every 6 months
Final visit (Fixed study end date)
Bhatt DL, et al. Am Heart J

28. CHARISMA: Overall Population: Primary Efficacy Outcome (MI, Stroke, or CV Death)†
Placebo + ASA*
7.3% 8
Clopidogrel + ASA*
6.8% 6
Cumulative event rate (%) 4
RRR: 7.1% [95% CI: -4.5%, 17.5%]
P=.22 2 6 12 18 24 30
Months since randomization§
† First Occurrence of MI (fatal or non-fatal), stroke (fatal or non-fatal), or cardiovascular death
*All patients received ASA mg/day
§The number of patients followed beyond 30 months decreases rapidly to zero and there are only 21 primary efficacy events that occurred beyond this time (13 clopidogrel and 8 placebo)
Bhatt DL, et al. N Engl J Med

29. CHARISMA Primary Efficacy Results (MI/Stroke/CV Death) by Pre-Specified Entry Category
Population RR (95% CI) P value
Qualifying CAD, CVD or PAD (0.77, 0.998) .046
(N=12,153)
Multiple Risk Factors (0.91, 1.59) .20 (N=3,284)
Overall Population* 0.93 (0.83, 1.05) .22 (N=15,603)
0.4
0.6
0.8
1.2
1.4
1.6
Clopidogrel Better
Placebo Better
*A statistical test for interaction showed marginally significant heterogeneity (P=.045) in treatment response for these pre-specified subgroups of patients
Bhatt DL, et al. N Engl J Med

30. Primary Outcome Event Rate (%) Months Since Randomization
CHARISMA – Prior MI 10 8 6 4 2
N=3,846
8.3%
Placebo + ASA
Clopidogrel + ASA
6.6%
Primary Outcome Event Rate (%)
HR=0.774 (95% CI [0.613–0.978])
P=.031 6 12 18 24 30
Months Since Randomization
Bhatt DL, et al. J Am Coll Cardiol

31. Clopidogrel should be considered in a non-diabetic patient with high risk for atherosclerosis but has not had an episode of ACS.
True
False
B: False. Charisma should no benefit in patients with risk and no prior event of ACS.  
Countdown 10

32. P2Y12 Inhibitor Therapy After Stenting

33. Coronary Stenting Lesion crossed with guidewire Lesion dilated
with balloon
Stent aligned
in lesion
Deployed stent
In artery

34. Coronary Stenting
Pre-PTCA
Post-Balloon
Post-Stent

35. CREDO: One Year Primary Outcome
Stable CAD and ACS Patients Rx with Bare Metal Stents (BMS) 5 15 10
27% RRR
P=.02
Placebo
N=1063
11.5%
8.5%
Death, MI, or Stroke
Clopidogrel
N=1,053 3 6 9 12
Months
Steinhubl SR, et al. JAMA

36. Continued Risk of Drug Eluting Stent (DES) Thrombosis DES Stent Thrombosis In The Bern/Rotterdam Two Center Experience 1 3 2 4
Paclitaxel DES
Stent Thrombosis (%)
Sirolimus DES
,095
Days After Stenting
P. Wenaweser and P.W. Serruys, ESC 2006.
(Slide courtesy of Roxana Mehran, Columbia University)

37. Newer P2Y12 Inhibitors
∙ Prasugrel ∙ Ticagrelor

38. Prasugrel Thienopyridine “Irreversible” platelet inhibition
Rapidly metabolized prodrug
Rapid onset of action
Greater and more reliable platelet inhibition than clopidogrel
Bhatt DL. N Engl J Med. 2009;
van Giezen JJ. Eur Heart J Suppl

39. Prasugrel vs. Clopidogrel Platelet Aggregation (%)
PRINCIPLE-TIMI 44
Prasugrel vs. Clopidogrel
Loading Dose
Maintenance Doses
100 *
P<.001 vs. Clop 300 mg or 600 mg LD
Pras 60 mg
Pras 10 mg 80 † !
P<.001 vs. Clop 300
P<.05 vs. Clop 300 §P<.05 vs. Clop 300/75
Clop 600 mg
Clop 75 mg
Platelet Aggregation (%)
Inhibition of 60
Clop 300 mg
Clop 75 mg 40 20
mean ± SEM 20 μM ADP
0.25
0.5 1 2 4 6 24 3 4 5 6 7 8 9
Time
Hours
Days
Wiviott SD, et al. Circulation

40. TRITON-TIMI 38: Study Design
ACS (STEMI or UA/NSTEMI) and Planned PCI
ASA
N=13,600
Double-blind
CLOPIDOGREL
300 mg LD/75 mg MD
PRASUGREL
60 mg LD/10 mg MD
Median duration of therapy: 12 months
1o endpoint: CV death, MI, Stroke
2o endpoints: CV death, MI, Stroke, Rehospitalization for Recurrent Ischemia CV death, MI, UTVR Stent Thrombosis (ARC definite/prob.) Safety endpoints: TIMI major bleeds, Life-threatening bleeds Key Substudies: Pharmacokinetic, Genomic
LD=loading dose; MD=maintenance dose
Wiviott SD, et al. N Engl J Med

41. Timing of Benefit: Landmark Analysis
TRITON-TIMI 38
Timing of Benefit: Landmark Analysis 8
6.9
Clopidogrel
Clopidogrel 6
5.6
5.6
Primary Endpoint (%)
(CV death, MI, CVA)
4.7 4
Prasugrel
Prasugrel
HR 0.82 P=.01
HR 0.80 P=.003 2 1 1 2 3 30 60 90
180
270
360
450
Loading Dose
Days
Maintenance Dose
Wiviott SD, et al. N Engl J Med

42. TRITON-TIMI 38: Definite and Probable Stent Thrombosis1 2
2.5
2.4 (142)
Clopidogrel
Any Stent at Index PCI N=12,844
Definite & Probable Stent Thrombosis (%)
1.1 (68)
Prasugrel
HR 0.48 P<.0001
NNT=77 30 60 90
180
270
360
450
Days
Wiviott SD, et al. N Engl J Med

43. TRITON-TIMI 38: Bleeding Events
Clopidogrel
Prasugrel
ICH in Pts with Prior Stroke/TIA (N=518)
Clopidogrel 0 (0%) Prasugrel 6 (2.3%)
P=.02
P=.03
P=.01
% Events
P=NS
P=.002
P=NS
ARD 0.6% HR 1.32
ARD 0.5% HR 1.52
ARD 0.2%
ARD 0.3%
ARD 0%
ARD=absolute risk difference
Wiviott SD, et al. N Engl J Med

44. TRILOGY ACS Study Design
Medically Managed UA/NSTEMI Patients
Randomization Stratified by:
Age, Country, Prior Clopidogrel Treatment
(Primary analysis cohort — Age <75 years)
Median Time to Enrollment=4.5 Days
Clopidogrel* 300 mg LD +
75 mg MD
Prasugrel* 30 mg LD
5 or 10 mg MD
Medical Management Decision ≤72 hrs
(No prior clopidogrel given) – 4% of total
Medical Management Decision ≤ 10 days
(Clopidogrel started ≤72 hrs in-hospital OR
on chronic clopidogrel) – 96% of total
Clopidogrel*
75 mg MD
Prasugrel* 5 or 10 mg MD
Minimum Rx Duration: 6 months; Maximum Rx Duration: 30 months
Primary Efficacy Endpoint: CV Death, MI, Stroke
*All patients were on aspirin and low-dose aspirin (<100 mg) was strongly recommended. For patients <60 kg or ≥75 years, 5 mg MD of prasugrel was given
Adapted from Chin CT, et al. Am Heart J

45. TRILOGY ACS: Primary Efficacy Endpoint*20
HR ≤1Year: 0.99
(0.84, 1.16)
HR >1 Year: 0.72
(0.54, 0.97)
16.0% 15
13.9% 10
Clopidogrel
Prasugrel
HR: 0.91
P=.21 (NS) 5
Interaction P=.07
Time, days
No. at risk
Prasugrel: 3,620 3,248 2,359 1,
Clopidogrel: 3,623 3,244 2,390 1,
*Primary endpoint=CV death, nonfatal MI, nonfatal stroke **Primary analysis excludes age >75 yrs
Roe MT, et al. N Engl J Med

46. Ticagrelor Non-thienopyridine “Reversible” binding of P2Y12 receptor
Active drug
Quick onset of action
Greater degree of and more reliable platelet inhibition than clopidogrel
Bhatt DL. Nature Reviews Cardiology. 2009;
van Giezen JJ. Eur Heart J Suppl

47. Inhibition of Platelet Aggregation (IPA)
DISPERSE 2
Comparative Effects on Platelet Aggregation of Ticagrelor vs. Clopidogrel
Inhibition of Platelet Aggregation (IPA) 25 50 75
100
Ticagrelor 90 mg
Ticagrelor 180 mg
Ticagrelor 270 mg
Clopidogrel 300 mg
IPA, % (mean ± SEM) 2 4 6 8 10 12
Time Post Dose (Hours)
Keeley EC, et al. Lancet

48. PLATO Study Design
NSTEMI-ACS (moderate-to-high risk), STEMI (if primary PCI)
Clopidogrel-treated or -naive;
randomized within 24 hours of index event
(N=18,624)
Clopidogrel
If pretreated, no additional loading dose;
if naive, standard 300 mg loading dose,
then 75 mg QD maintenance;
(additional 300 mg allowed pre-PCI)
Ticagrelor
180 mg loading dose, then
90 mg BID maintenance;
(additional 90 mg pre-PCI)
6-12-month exposure
Primary endpoint: CV death + MI + Stroke
Primary safety endpoint: Total major bleeding
Wallentin L, et al. N Engl J Med

49. PLATO: Time to Primary Efficacy Endpoint*12 11 10 9 8 7 6 5 4 3 2 1 13
Clopidogrel
11.7%
9.8%
Ticagrelor
Cumulative incidence (%)
HR 0.84 (95% CI )
P=.0003 60
120
180
240
300
360
Days after Randomisation
No. at risk
Ticagrelor
9,333
8,628
8,460
8,219
6,743
5,161
4,147
Clopidogrel
9,291
8,521
8,362
8,124
6,650
5,096
4,047
*Composite of CV death, MI, or stroke
Wallentin L, et al. N Engl J Med

50. PLATO: Secondary Efficacy Endpoints
Myocardial infarction
Cardiovascular death 7
6.9 7
Clopidogrel 6 6
5.8
Clopidogrel
5.1 5 5
Ticagrelor 4 4
4.0
Cumulative incidence (%)
Cumulative incidence (%)
Ticagrelor 3 3
HR 0.84 (95% CI )
P=.005 2 2
HR 0.79 (95% CI ) P=.001 1 1 60
120
180
240
300
360 60
120
180
240
300
360
Days after randomisation
Days after randomisation
Wallentin L, et al. N Engl J Med

51. PLATO: Overall, Non-CABG and CABG-related Major Bleeding
P=.57 (NS)
P=.43 (NS)
PLATO criteria major bleeding 1 2 3 4 5 6 7 8 9 10 12 11 13
TIMI criteria major bleeding
11.6
11.2
7.9
7.7
Ticagrelor Clopidogrel
P=.026
P=.025
P=.32 (NS) 9
Non-CABG PLATO major bleeding 8 7 6 5 4 3 2 1
Non-CABG TIMI major bleeding
CABG PLATO major bleeding
CABG TIMI major bleeding
4.5
3.8
2.8
2.2
7.4
7.9
5.3
5.8
Estimated Rate (% per year)
Wallentin L, et al. N Engl J Med

52. PLATO: Stent Thrombosis*
Ticagrelor
(N=5,640)
Clopidogrel
(N=5,649)
HR (95% CI)
P Value
Definite
71 (1.3%)
106 (1.9%)
0.67 ( )
.009
Probable of definite
118 (2.1%)
158 (2.8%)
0.75 ( )
.02
Possible, probable, or definite
155 (2.8%)
202 (3.6%)
0.77 ( )
.01
*Evaluated in patients with any stent during the study
Wallentin L, et al. N Engl J Med

53. PLATO: Initial Non-Invasive Strategy Subgroup
Cardiovascular death, MI, or Stroke (%) 20
N=5,216 (1/4 total study population, 1/3 NSTE-ACS population)
In-hospital procedures: cath 41.9%; PCI 20.4%; CABG 4.0%
By final follow-up: revascularization 40% (PCI only 72.6%; CABG only 25.8%; both 1.6%) 16
14.3%
HR 0.85
P=.04
Clopidogrel
12.0% 12
Ticagrelor 8 4
Days after Randomization
James SK, et al. BMJ

54. PLATO: Initial Non-Invasive Strategy Subgroup10
All-cause Mortality (%)
N=5,216
In-hospital procedures: cath 41.9%; PCI 20.4%; CABG 4.0%
By final follow-up: revascularization 40% (PCI only 72.6%; CABG only 25.8%; both 1.6%) 8
8.2%
HR 0.75
P=.01
Clopidogrel
6.1% 6
Ticagrelor 4 2
Days after Randomization
James SK, et al. BMJ

55. Summary of P2Y12 Inhibitor Properties and Use
Clopidogrel
Prasugrel
Ticagrelor
Class
Thienopyridine
Triazolopyrimidine
“Reversibility”
Irreversible
Reversible
Activation
Prodrug, limited by metabolism
Prodrug, not limited by metabolism
Active drug
Onset of effect
2-4 hr
30 min
Duration of effect
3-10 days
5-10 days
3-4 days
Withdrawal before major elective surgery
5 days
7 days
Contraindications/
Caveats
600 mg loading dose (not FDA approved) provides faster, greater, and more reliable platelet inhibition
CYP2C19 *2 or *3 alleles are poor metabolizers and have reduced antiplatelet effects
Contraindicated in patients with hx CVA/TIA
Generally not recommended in patients age >75 years (bleeding risk)
Increased bleeding risk if body weight <60 kg
Concomitant ASA dose should be <100 mg
Contraindicated if severe hepatic impairment
Avoid use with strong CYP3A inhibitors* or CYP3A inducers**
Both tracks apply
*clarithromycin, ketoconazole, indinavir, itraconazole, etc.
**rifampin, carbamazepine, dexamethasone, phenytoin, phenobarbital
Based in part from Hamm CW, et al. Eur Heart J. 2011, as well as drug PIs and study protocols.

56. Which of the following features do prasugrel and ticagrelor NOT share?
Platelet receptor target
Superiority over clopidogrel in preventing stent thrombosis
Once-daily dosing
No generic formulation available
Answer is C: prasugrel is QD, ticagrelor is BID
Countdown 10

57. Patients on ticagrelor should be on a dose of aspirin under 100 mg per day.
True
False
A: True. Plato showed less of an effect for ASA dosages >100mg and is contraindicated on dosages >100mg.
Countdown 10

58. 2012 ACCF/AHA Selected Recommendations for Antiplatelet Therapy in UA/NSTEMI
COR
LOE
Early Invasive Strategy, Medium to High Risk Patients:
Aspirin indefinitely I A
P2Y12 inhibitor therapy (clopidogrel, ticagrelor, or prasugrel) in post-PCI patients at least 12 months B
If the risk of morbidity because of bleeding outweights the anticipated benefits afforded by P2Y12 receptor inhibitor therapy, earlier discontinuation should be considered C
Initial Conservative (noninvasive) Strategy
P2Y12 inhibitor therapy (clopidogrel or ticagrelor) for up to 12 months
COR=class of recommendation; LOE=level of evidence; ACCF=American College of Cardiology Foundation; AHA=American Heart Association; GPI =glycoprotein IIb/IIIa Inhibitor
Jneid H, et al. J Am Coll Cardiol

59. 2011 ACCF/AHA/SCAI PCI Recommendations: P2Y12 Inhibitor Therapy with Coronary Stents
LOE
P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor for at least 12 months in patients receiving a stent (BMS or DES) during PCI for ACS I B
Clopidogrel for at least 12 months in patients treated with a DES for a non-ACS indication, if patients are not at high risk of bleeding
Clopidogrel for a minimum of 1 month and ideally up to 12 months in patients receiving a BMS for a non-ACS indication (unless the patient is at increased risk of bleeding; then it should be given for a minimum of two weeks)
Earlier discontinuation (e.g., <12 months) of P2Y12 inhibitor therapy after stent implantation if the risk of morbidity from bleeding outweighs the anticipated benefit afforded by a recommended duration of P2Y12 inhibitor therapy
IIa C
Continuation of DAPT beyond 12 months in patients undergoing DES implantation
IIb
Levine GN, et al. J Am Coll Cardiol

60. ESC Recommendations for P2Y12 Inhibitors in Patients with CKD
Clopidogrel
Experience is limited in patients with severe renal impairment; use with caution
Prasugrel
No dosage adjustment is necessary for patients with renal impairment; limited experience in ESRD
Ticagrelor
No dose reduction is necessary for patient with renal impairment; limited experience in dialysis
Hamm CW, et al. Eur Heart J

61. Prasugrel is NOT indicated for ACS patients that will undergo a PCI.
True
False
B: False. Only indicated for patients undergoing PCI.
Countdown 10

62. PPI Treatment With Dual Oral Antiplatelet Therapy (DAPT)

63. COGENT Trial – Effect of PPI on Composite GI Events
Omeprazole
1.00
Placebo
0.90
Probability of Freedom from Primary GI Endpoint
HR 0.34, 95% CI
P<.001 by the log-rank test
0.00 50
100
150
180
200
Time (Days)
No. at Risk
Placebo 1,885 1,
Omeprazole 1,876 1,
Bhatt DL, et al. N Engl J Med

64. COGENT Trial – Effect of PPI on Composite Cardiovascular Events
1.00
Omeprazole
Placebo
Probability of Freedom from Primary CV Endpoint
0.90
HR 0.99, 95% CI
P=.98 by the log-rank test
0.00 50
100
150
180
200
Time (Days)
No. at Risk
Placebo 1,885 1,
Omeprazole 1,876 1,
Bhatt DL, et al. N Engl J Med

66. PPI Therapy and DAPT Recommendations Based on Risk of GI Bleeding
COR
LOE
PPI use for patients with history of prior GI bleeding who require DAPT I C
PPI use for patients with increased risk of GI bleeding (advanced age, concomitant use of warfarin, steroids, NSAIDs, H. pylori infection, etc.) who require DAPT
IIa
Routine use of a PPI for patients at low risk of GI bleeding, who have much less potential to benefit from prophylactic therapy
III: No Benefit

67. How Much of the Patient Are We Treating?
=1/5,000,000
Courtesy of Steven Steinhubl.

68. Established Therapies Are Consistently Underused in All Patient Types
Patients Not Receiving Therapy
(% of subpopulation)
Bhatt DL, et al. JAMA

69. Placebo-Controlled Mega-Trials of Statin Therapy in Primary and Secondary Prevention
% Reduction in Primary Endpoint

70. NCEP ATP III
Latest Recommendations for Primary and Secondary Screening, Prevention, and Therapy: Secondary Prevention
All patients hospitalized for CAD should have lipid profile obtained within 24 hours of admission
All patients with CAD should be screened
Drug Rx can be started simultaneously with life-style changes
CAD-equivalents include:
PVD, AAA, carotid disease
Diabetes
Multiple CRF conferring high risk of developing CAD
Goal: LDL <100 mg/dL
Grundy SM, et al. J Am Coll Cardiol

71. NCEP ATP III Update
Emphasized LDL <100 mg/dL is a “minimal goal of therapy” for secondary prevention
Consider goal of <70 mg/dL in very high risk patients
These patients are those with established CVD plus:
Multiple major risk factors (especially DM)
Severe and poorly controlled risk factors (especially continued smoking)
Multiple risk factors of metabolic syndrome (TG >200, etc.)
Patients with ACS
Grundy SM, et al. J Am Coll Cardiol

72. Good glycemic control in diabetic patients Dual antiplatelet therapy
Which of the following medical therapies is MOST effective at preventing stent thrombosis?
Statins
Beta blockers
ACEI-ARB
Good glycemic control in diabetic patients
Dual antiplatelet therapy
Good blood pressure control in hypertensive patients
ANSWER: E. The other measures all help prevent progression of disease but not ST.
Countdown 10

73. Medication Adherence

74. Medication Adherence
One in three patients fail to fill their prescriptions
Approximately three of four Americans report they do not consistently take their medications as directed
Sixty percent of patients cannot correctly name their medications and up to 20% of patients take other people’s medications
Between 33 and 69 percent of medication-related hospital admissions in the U.S. are due to poor adherence
Approximately one-fourth of all nursing home admissions are related to improper self-administration of medications
In common chronic conditions such as diabetes and hypertension, adherence rates average between percent
National Transitions of Care Coalition. Available at:

75. Medication Adherence Decreases Over One Year
Study Design
Canadian Survey
1956 NSTEMI patients prospectively followed
Hospital and discharge data collected by chart review
One-year adherence data collected by patient telephone interview
Discharge
1 Year
*P=.03
**P<.001
% Patients
OA=oral anticoagulant
OMT=optimal medical therapy
Bagnall AJ, et al. Circ Cardiovasc Qual Outcomes

76. Reasons Medications Were Not Used Canadian Survey
Conclusions
Physicians underestimated risk or were misinformed about guidelines
One third of EBT nonadherent patients had stopped their own treatment
Antiplatelet, β-blocker, and ACEI use declined during the year after discharge
Suggested solutions
Discharge contract signed by patient
Cardiac rehab and education
Bagnall AJ, et al. Circ Cardiovasc Qual Outcomes

77. Predictors of Antiplatelet Discontinuation One-Year Follow-Up After DES Implantation
OR, odds ratio of discontinuation of antiplatelet therapy
Ferreira-González I, et al. Circulation

78. Medicare Fee-for-Service
Rehospitalizations:
Medicare Fee-for-Service
Analysis of Medicare Claims data from
Includes the 11,855,702 Medicare beneficiaries discharged from the hospital
Summary Analysis
19.6% (nearly 1/5) were rehospitalized within 30 days
34% were rehospitalized within 90 days
50.2% of those rehospitalized within 30 days after a medical discharge there was no bill for a visit to a physician office
Jencks FS, et al. N Engl J Med

79. Case Study
Jose is a 66-year-old gentlemen with a h/o HTN and dyslipidemia, transferred to the tele floor from the ICU with the Dx of a STEMI and implantation of a drug-eluting stent (DES).
The patient and his family were poor historians on admission and it is unclear whether his medical and medication history are accurate.
Jose is anxious to “get out of here” and thinks this is “no big deal”.

80. Continuity of Care:
Key Information Exchange Between the Inpatient Team and the Primary Care Team

81. Pre-hospitalization and Hospitalization
Medication reconciliation during pre-hospitalization may be complicated by the lack of a reliable source of medication history and should be re-evaluated 24 hours after the patient is admitted
Contact with the PCP is appropriate during the hospital stay, and may offer valuable insight about issues related to discharge planning
A particular challenge of ACS care is the extensive amount of complex information which must be shared quickly and accurately with all stakeholders
The risk of miscommunication is real

82. Case Study, Continued…
Jose’s PCP provided more information about his medical and medication history
His father died of a heart attack at age 62
Smoked on/off for several years and has been poorly compliant with diet, exercise, and taking statins
He may not comprehend the seriousness of his heart disease and how secondary preventive measures may reduce his risk of further events
His history of poor adherence raises concern that he will not persist with recommended ACS medications after discharge

83. Discharge and Post-Discharge
Discharge is one of the most crucial transitions in care, with potential impact on patient outcomes post-discharge, including readmission
The discharge summary is an obvious target for quality improvement, as it is the most common vehicle for sharing patient information with the PCP and other healthcare providers

84. Overcoming Barriers to Communication
Poor literacy
Poor English proficiency
Poor understanding of medical jargon
Inadequate time with the clinician for questions and answers
Poor cognition
Lack of communication between healthcare professionals, specifically among physicians
Financial barriers to medication use

85. Case Study, The Finale…
After verbally describing his discharge medications to Jose and his family, and providing written patient materials, you ask Jose to explain why his prescribed dual antiplatelet therapy is important
A consult is requested from pharmacy for additional counseling
Because you have been in direct contact with the PCP, you call now to express your concerns, in addition to noting Jose’s poor comprehension in the discharge summary

86. Transitioning the Patient With ACS From Inpatient to Primary Care
Timely and accurate communication between the inpatient team and the PCP/PCHM is a vital component of a safe transition from inpatient to primary care.
Communication directly impacts the continuity of care, patient outcomes, patient and caregiver satisfaction, and use of health care resources.
The inpatient team should be cognizant of gaps in care related to how information is generated, recorded, and shared between the inpatient setting and primary care.
The inpatient team responsibility for the patient does not end at the time of discharge. All reasonable effort should be done to assure that our patients, their caregivers and their outpatient providers are given all the tools necessary to complete and maintain the patient’s therapy.
Patients with acute coronary syndrome (ACS) are a challenge for the hospitalist, as they require substantial coordination of care and support during hospitalization and in the transition back into primary care. ACS accounted for 733,000 discharge diagnoses in 2006 (inclusive of unstable angina or acute myocardial infarction [MI]), and the American Heart Association considers this a conservative estimate.1 Readmission of these patients occurs with some frequency and expends healthcare resources. A multiemployer claims database showed a 20% rehospitalization rate for patients with ischemic heart disease within one year of discharge after ACS.2
Introduction
Implementation of evidenced-based care for patients with ACS and an emphasis on preventive measures for coronary heart disease (CHD) has directly improved CHD–related outcomes. A 2007 study revealed that almost one half of the 40% decrease in CHD–related mortality between 1988 and 2000 was directly attributable to therapeutic interventions and reductions in recognized risk factors for CHD. However, this news was tempered by the effect of two risk factors, increased body mass index and diabetes, which accounted for additional CHD–related deaths in
The Society of Hospital Medicine (SHM) has established core competencies for hospitalists who manage patients with ACS, defining the scope of interactions between the hospitalist, patient, and other clinicians such as specialists and primary care providers (PCP).4,5 Several competencies focus on ACS and transitions in care, requiring the hospitalist to demonstrate the skills and attitudes outlined in Table 1. Of concern is the risk for adverse events associated with medication errors and lack of follow-up related to diagnostic tests during the postdischarge period, which in turn raises the risk of readmission.6 The hospitalist is in a unique position to have a positive impact on the transition from inpatient to primary care by proactively addressing patient–specific issues through careful planning and coordination with the patient, the PCP, and other stakeholders.
Jose is a 66-year-old retiree recovering on the medical floor after diagnosis of a STEMI and implantation of a drug-eluting stent (DES). Jose and his family were poor historians on admission and it is unclear whether his medical and medication history are accurate. Jose is anxious to “get out of here” and thinks this is “no big deal”. Upon admission Jose was hypertensive and mildly obese. He denies smoking and exercises “once in awhile” by working in his yard. His lipid profile on admission indicated elevated LDL and total cholesterol.
Case Study
You decide to address several issues during Jose's hospital stay. These include contacting Jose’s PCP to obtain a complete medical and medication history, and educating Jose about his cardiac disease, his risk of future events, and strategies for risk reduction.
Continuity of Care: Key Information Exchange Between the Hospitalist and the Primary Care Physician
Prehospitalization and hospitalization are critical times for the patient with ACS: decisions not only affect the inpatient course but lay the groundwork for care after discharge. For ACS in particular, early identification and understanding of a patient’s risk for further ischemic events is critical to determining the therapeutic course, and evidence shows that timely intervention decreases morbidity and mortality.7,8 Notably, the evaluation and risk stratification of patients with ACS are hospitalist core competencies (Table 1); the initiation of a beta-blocker and antiplatelet therapy are considered by the Center for Medicare and Medicaid Services (CMS) to be core measures by which to measure the quality of hospital care. The hospitalist may provide oversight and assure that care is coordinated and patients are assessed and triaged in a timely manner according to recommended guidelines.
Prehospitalization and Hospitalization
Information-gathering and evaluation begins in the emergency department (ED)9 (Table 2) and continues after admission9 (Table 3), when the hospitalist may need to seek additional medical and medication history to inform risk assessment. In fact, risk assessment should continue throughout the hospital stay as additional diagnostic information is acquired and consultations are provided. Medication reconciliation started during prehospitalization may be complicated by the lack of a reliable source of medication history and should be re-evaluated 24 hours after the patient is admitted. Contact with the PCP is appropriate during the hospital stay, with the hospitalist apprising the PCP of diagnoses, interventions, and major clinical events during hospitalization. The PCP may offer valuable insight about issues related to discharge planning. Prehospitalization and hospitalization are also opportunities for the PCP to anticipate receiving the patient back into outpatient care.
Discharge planning ideally begins soon after admission in order to adequately address issues which may complicate recovery. Medication reconciliation continues during discharge planning, and CMS core measures still apply relative to the use of beta-blockers and antiplatelet therapies. Confirming the accuracy of the patient's medication history during hospitalization is an important step in medication reconciliation to ensure that therapies are appropriate and to avoid discrepancies in discharge medications.
A particular challenge of ACS care is the extensive amount of complex information which must be shared quickly and accurately with all stakeholders. The risk of miscommunication is real, but systems and tools are available to lower this risk. At this juncture, technology-based resources can be especially useful for obtaining and organizing information. Standardized order entry programs or order sets are a reliable method that clinicians can use to meet quality standards during the patient's hospitalization and are highly recommended for patient safety. The SHM ACS Transitions Workgroup has also developed an adaptable multidisciplinary tracking tool that can be used to monitor a patient with ACS through the anticipated transitions in care; this tool includes several examples of order sets that can be adapted to each institution.10
Discharge is one of the most crucial transitions in care, with potential impact on patient outcomes postdischarge, including readmission. In the past decade, initiatives to improve the discharge process, particularly discharge summaries,11 have yielded standards and tools to improve the process. Current standards for a safe discharge12,13 are summarized in Table 4. Additionally, the SHM has developed a discharge checklist14 (Table 5) and a template15 for the discharge summary, each to facilitate communication between stakeholders. The discharge summary is an obvious target for quality improvement, as it is the most common vehicle for sharing patient information with the PCP and other healthcare providers. Essential elements of a discharge summary are content (Is key information captured?); format (Is content clear, concise, and accurate?); and delivery (Does the discharge summary reach the right people in a timely manner?).
Discharge and Postdischarge
Evidence indicates that the danger for patients at discharge is often related to medication reconciliation, adverse drug events, and pending test results or testing needed after hospitalization.6 Errors affect a sizable proportion of patients, with 49% of patients in one study subject to 1 medical error within 2 months of discharge. This error was directly attributed to discontinuity during the transition from hospitalist care to the affiliated PCP practice. Errors were related to discharge medications, test results, or lack of PCP follow-up on testing recommended by the inpatient provider (a work-up error). Patients with a work-up error were 6 times more likely to be rehospitalized in the 3 months following the first outpatient visit.16 Another study found that 41% of discharged patients had inhospital test results return after they were discharged and that PCPs were often unaware of these results. In some of these cases, test results required action, sometimes urgently.17
Most adverse events after discharge appear to be adverse drug events (ADEs), with up to two thirds identified as preventable or ameliorable Forster and colleagues found that ADEs resulted in significant injury in 71% of patients, serious injury in 13%, and life-threatening injury in 16%.20 ADEs also resulted in 27% of patients requiring emergency care or readmission. Anticoagulants and cardiovascular medications were ranked high among medications associated with an ADE; failure to monitor medications was the most common cause of a preventable or ameliorable ADE. Patients had good recall of general drug information provided at discharge; patients who could not recall receiving specific information about ADEs were more likely to have an ADE. This is an area of opportunity for the hospitalist to improve patient safety during the transition to primary care. It is also of special concern for patients with ACS, given the complexity of medication regimens and the potential for serious drug reactions.
The risk of adverse events after discharge is higher in certain populations such as the elderly. Project BOOST (Better Outcomes for Older adults through Safe Transitions) is a quality improvement initiative to improve patient care during discharge.21 BOOST aims to reduce 30-day readmission rates for general medicine patients (especially older adults), improve patient satisfaction, improve communication between the institution and the PCP, identify high-risk patients and mitigate risk, and improve patient and family education with a focus on patient–specific risk factors.
BOOST uses a multidisciplinary “7P Screening” tool to identify high-risk patients, specifically through discharge planning and risk stratification.21 Seven areas are assessed: problem medications, punk (depression), principal diagnosis, polypharmacy, poor health literacy, patient support, and prior hospitalization. For each, specific interventions are recommended to lower the risk of untoward events. 7P Screening applies to patients with ACS and can be an important step in identifying concerns at discharge, with the goals of promoting recovery and reducing the risk of readmission. The BOOST tool also includes a Universal Patient Discharge List reflective of those proposed by Project RED (Re-Engineered Discharge) and the SHM. However, BOOST suggests additional steps to enhance communication: multidisciplinary rounds at discharge, direct communication with the PCP before discharge, phone contact with the patient or caregiver within 3 days of discharge, and phone numbers for hospital personnel familiar with the patient if the patient is unable to reach the PCP about an issue before the patient's first scheduled follow-up visit. These steps recognize the value of direct communication between the hospitalist, the patient, and the PCP.
Communication deficits between the hospitalist and PCP6 show that recognizing barriers and finding solutions is especially important given the complex nature of ACS and the importance of adhering to secondary prevention measures. A successful transition from the hospital to primary care rests largely on the quality of communication between the hospitalist and the PCP. However, only 56% of PCPs expressed satisfaction with the communication they have with hospitalists, indicating that improvement is needed. The PCPs surveyed noted that direct and frequent communication is desired, with three quarters preferring to speak with the hospitalist by phone at both the patient's admission and discharge.22 However, direct communication between providers was infrequent, occurring in only 3%–20% of cases.11
Overcoming Barriers to Communication Between the Hospitalist and the PCP at Discharge
PCPs deemed discharge medications and discussion of the reasoning for medication changes and duration of treatment, diagnoses, physical findings, test results, follow-up needs and plan details, and pending test results to be the most important shared information,11,22 but this information is frequently unavailable. Details about patient or family counseling is most often missed in 90%–92% of summaries, followed by pending test results at discharge in 65%, inhospital test results in 33%–63%, discharge medications in 2%–40%, and a description of the follow-up plan in 2%–43%. Structured discharge summaries can yield organized and easily retrievable information, with the structure providing cues to include all necessary details.11 These may be computer-generated vs traditional dictated or handwritten summaries.6
Even though it is recommended that discharge summaries be dictated contemporaneously, late discharge summaries are recognized as another communication barrier during the patient's transition to primary care.11 For one quarter to one third of patients, discharge summaries are not available for the first or even subsequent outpatient visits.11,22,23 This is even more problematic when the PCP is unaware of the patient's hospitalization; the timely receipt of the discharge summary can greatly facilitate follow-up care.24 Emphasis should also be placed on sending the information to the cardiologist and other physician stakeholders who will also be seeing the patient for follow-up. One approach is to prepare an interim discharge note on the day of discharge, to be sent by facsimile, phone, or ,6 that contains minimum required information, such as diagnosis, medications, test results, follow-up needs, and pending test results.11 Interventions such as computerized discharge summaries and using the patient as a courier have been shown to help.11 In fact, a systematic discharge process using a standardized discharge form, electronic delivery of the discharge summary, and nursing follow-up from the PCP’s office assured that more patients had timely follow-up from their PCP. This also reduced the number of incomplete work-ups recommended by the hospitalist; in a few cases, the nursing follow-up call resulted in a change in the treatment plan based on new developments after the patient's discharge.25
Use of standardized instruments such as the SHM transitions tool facilitates the delivery of timely and accurate information. Within an institution, these tools enhance the flow of communication and alert multidisciplinary providers to assess patients and intervene to address issues prior to discharge. A standardized toolkit reportedly reduced the number of return visits to the ED within 3 days of discharge; at 30 days there were fewer ED visits and readmissions. This toolkit, employed starting with admission, contained the following: a standard admission form, facsimile to the PCP at admission, a worksheet to identify barriers at discharge, pharmacist–physician medication reconciliation, and predischarge planning appointments.26
It is worth noting that patients and their caregivers also have barriers to communication that should be addressed by the time of discharge. These barriers include poor literacy, poor English proficiency, poor understanding of medical jargon, inadequate time with the clinician for questions and answers, poor cognition, highly complex information, and a diagnosis the patient may consider overwhelming.6 Specifically, patients with ACS demonstrated a poor comprehension of their medication regimen after discharge, manifested as either a delay or not filling of prescriptions, followed by poor adherence to the regimen.27 Hospitalists can address some patient barriers during discharge planning and discharge; specifically, they can improve counseling and communication relative to medications so that patients know how and why they are taking a medication and how their discharge medications reconcile with those they were familiar with prehospitalization. Financial barriers to medication use, either because of direct cost or restriction in outpatient formularies, should be identified prior to discharge. Patients report that a follow-up call from the clinician after discharge or pharmacist counseling before discharge, and use of a pillbox would remove some barriers to adherence. In teach-back, patients are asked to repeat instructions in their own words, avoiding yes or no answers, thereby revealing gaps in understanding. This strategy checks patient comprehension and provides an opportunity for dialog if it is apparent that patients do not understand information related to their disease and recovery.
Jose’s PCP provided more information about his medical and medication history. His father died of a heart attack at age 62. Jose has smoked on and off for several years and has been poorly compliant with measures to reduce his risk for coronary heart disease such as diet, exercise, and taking statins. Jose may not comprehend the seriousness of his heart disease and how secondary preventive measures may reduce his risk of further events. His history of poor compliance raises concern that he will not persist with recommended ACS medications after discharge.
Evidenced-based guidelines stress the need for aggressive modification of risk factors and treatment with antiplatelet, antihypertensive, and lipid-lowering agents started during hospitalization and continued long-term as part of secondary prevention strategies.7,8 There is a missed opportunity for improving patient outcomes after ACS,28,29 shown by the underuse of guideline-recommended therapies (antiplatelet therapies such as clopidogrel and aspirin, beta-blockers, angiotensin–converting enzyme (ACE) inhibitors, and statins).30 Over one half of patients stopped evidence-based medications without input from their providers, partly attributed to patients' perception that medication was not needed.28,29,31 Through education, the hospitalist can directly influence patient and caregiver understanding of the benefit of ACS medications and their effect on long-term outcomes.
Impact of the Hospitalist on Long-term Outcomes
Educating the patient and family about the nature, prognosis, and treatment of cardiac disease is equally important, and secondary prevention measures should be addressed prior to discharge. Prevention includes urging the patient to make therapeutic lifestyle choices such as smoking cessation (a core measure), maintaining a healthy diet, and regular exercise. The plan to address these issues should be communicated to the PCP, because adherence to behavioral changes after ACS has been shown to be poor and to directly impact outcomes. In one study, one third of smokers continued to smoke after one month and about one third of patients did not adhere to a recommended diet or exercise regimen. At 6 months, those patients who did quit smoking had a 43% lower risk of MI; compliance with the diet and exercise regimen lowered their risk of MI by 48%. Persistent smoking and nonadherence to diet and exercise resulted in an almost 4-fold increased risk of MI, stroke, or death vs never-smokers who adhered to diet and exercise recommendations.32 This presents a clear opportunity for the hospitalist to intervene and effect change. Assessment of needed secondary prevention measures should occur in preparation for discharge, and an emphasis on patient teaching and communicating the plan to the PCP may overcome patient barriers to adhering to recommended lifestyle changes.
Case Study (cont)
After verbally describing his discharge medications to Jose and his family, and providing written patient materials, you ask Jose to explain why his prescribed dual antiplatelet therapy is important. He states it will help his “occasional arthritis,” because aspirin is one of the drugs, revealing that Jose lacks understanding of why he is taking the antiplatelet therapies or why they are important. A consult is requested from pharmacy for additional counseling. Because you have been in direct contact with the PCP, you call now to express your concerns, in addition to noting Jose’s poor comprehension in the discharge summary.
Timely and accurate communication between the hospitalist and the PCP is a vital component of a safe transition from inpatient to primary care. This communication directly impacts the continuity of care, patient outcomes, patient and caregiver satisfaction, and use of health care resources. The role of the hospitalist is still evolving. Hospitalists will continue to have a pivotal role in transitions of care, and have a direct impact on the quality of the transition at discharge and patient outcomes after ACS. Hospitalists should be cognizant of gaps in care related to how information is generated, recorded, and shared between the inpatient setting and primary care, and should be proactive in identifying barriers and facilitating solutions. The hospitalist’s responsibility for the patient does not end at the time of discharge. We must make every reasonable effort to assure that our patients and their outpatient providers and caregivers are given all the tools necessary to complete and maintain the patient’s therapy.
Conclusion

87. Post-test

88. 67 year old man with history of DM and GI bleed six months ago is admitted with NSTE-ACS. Initial ECG showed anterolateral ST depressions and troponin levels rose to 1.3. He undergoes stenting of the LAD with a drug-eluting stent (DES). He is discharged to your care for further management.

89. What is the most appropriate daily dose of aspirin to treat him with long-term?
81 mg QD
325 mg (enteric coated) QD
325 mg BID (to better prevent stent thrombosis)
It doesn’t matter
A is correct
Countdown 10

90. It depends on which P2Y12 inhibitor he was placed on
How long should his P2Y12 inhibitor therapy (clopidogrel, ticagrelor, or prasugrel) be continued?
One month
3-6 months
At least 12 months
It depends on which P2Y12 inhibitor he was placed on C
Countdown 10

91. Should the patient be placed on a PPI?
It depends
Yes No
Maybe B