Sandbox:DN: Difference between revisions

Revision as of 13:52, 7 November 2016

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Overview

Dual antiplatelet therapy (or DAPT) refers to the combination of aspirin and a P2Y12 receptor antagonist. DAPT is approved for SIHD and interventions for ACS, such as stent placement following PCI or CABG. The duration of treatment with DAPT for each of these categories differs and guidelines for treatment have been updated in the 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease. Much of the studies done on DAPT compared the use of different types of P2Y12 receptor antagonists, the dosage of drugs, as well as the duration of treatment. The current consensus is that the use of DAPT is associated with decreased risk of stent thrombosis, MI and stroke. However, the benefits of treatment should be weighed against the increased risk of major bleeding in certain patient populations.

Types and Dosage of Drugs

Aspirin

Aspirin 81 mg once daily (range 75-100 mg) is used in all patients with SIHD, stent placement following PCI or CABG. The use of aspirin should be continued indefinitely.

P2Y12 Inhibitors

There are several P2Y12 inhibitors currently on the market and they are given in the following doses:

Clopidogrel: 75 mg once daily
Ticagrelor: 90 mg once daily
Prasugrel: 10 mg once daily

The drug of choice and duration of treatment depends on the medical condition and current recommendations.

Recommendations

The 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease includes recommendations for ACS treated with medical therapy and/or PCI, ACS treated with CABG, as well as stable ischemic heart disease:

The DAPT score

The DAPT score is a risk score derived from the DAPT Trial. It has been designed as a helpful tool for the continuation of dual antiplatelet therapy following PCI and the insertion of a drug-eluting stent (DES). A low DAPT score is associated with a higher risk of bleeding and a smaller reduction in ischemia. On the other hand, a high DAPT score translates into a greater reduction in ischemia, with a smaller risk of bleeding.


Variable	Points
Age ≥75 years	-2
Age 65 to less than 75 years	-1
Age less than 65 years	0
Current cigarette smoker	1
Diabetes Mellitus	1
MI at presentation	1
Prior PCI or prior MI	1
Prior PCI or prior MI	1
Stent diameter less than 3mm	1
Paclitaxel-eluting stent	1
CHF or LVEF less than 30%	2
Saphenous vein graft PCI	2

References

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 {| style="border: 0px; font-size: 90%; margin: 3px;" align=center
 |+
-! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Disease}}
+! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Variable}}
-! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Findings}}
+! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Points}}
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" | '''[[EHEC]]'''
+| style="padding: 5px 5px; background: #DCDCDC;" | '''Age ≥75 years'''
-| style="padding: 5px 5px; background: #F5F5F5;" | May present with [[fever]], [[chills]] [[vomiting]], [[diarrhea]], generalized [[pain]] or [[malaise]], and gastointestinal bleeding that follow an [[incubation period]] of 3-7 days. Unlike ''E. coli'', ''Shigella'' cannot ferment lactose or decarboxylate lysine.<ref name="NCBI">{{cite journal |last= Hale|first=TL |last2=Keusch|first2=GT |date=1996 |title=Shigella. In: Baron S, editor. Medical Microbiology. 4th edition.  |url=http://www.ncbi.nlm.nih.gov/books/NBK8038/ |journal=Galveston (TX): University of Texas Medical Branch at Galveston|access-date=4 April 2015}}</ref>
+| style="padding: 5px 5px; background: #F5F5F5;" | -2
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Ebola]]'''
+| style="padding: 5px 5px; background: #DCDCDC;" | '''Age 65 to less than 75 years'''
-| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[fever]], [[chills]] [[vomiting]], [[diarrhea]], generalized [[pain]] or [[malaise]], and sometimes [[Internal bleeding|internal]] and external [[bleeding]], that follow an [[incubation period]] of 2-21 days.
+| style="padding: 5px 5px; background: #F5F5F5;" | -1
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Typhoid fever]]'''
+| style="padding: 5px 5px; background: #DCDCDC;" | '''Age less than 65 years'''
-| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[fever]], [[headache]], [[rash]], gastrointestinal symptoms, with [[lymphadenopathy]], relative [[bradycardia]], [[cough]] and [[leucopenia]] and sometimes [[sore throat]]. [[Blood]] and [[stool culture]] can confirm the presence of the causative bacteria.
+| style="padding: 5px 5px; background: #F5F5F5;" | 0
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Malaria]]'''
+| style="padding: 5px 5px; background: #DCDCDC;" |'''Current cigarette smoker'''
-| style="padding: 5px 5px; background: #F5F5F5;" |Presents with acute [[fever]], [[headache]] and sometimes [[diarrhea]] (children). A [[blood smear]]s must be examined for malaria parasites. The presence of [[parasites]] does not exclude a concurrent viral infection. An [[antimalarial]] should be prescribed as an [[empiric therapy]].
+| style="padding: 5px 5px; background: #F5F5F5;" | 1
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Lassa fever]]'''
+| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Diabetes Mellitus]]'''
-| style="padding: 5px 5px; background: #F5F5F5;" |Disease onset is usually gradual, with [[fever]], [[sore throat]], [[cough]], [[pharyngitis]], and [[facial edema]] in the later stages. [[Inflammation]] and exudation of the [[pharynx]] and [[conjunctiva]] are common.
+| style="padding: 5px 5px; background: #F5F5F5;" | 1
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Yellow fever]] and other [[Flaviviridae]] '''
+| style="padding: 5px 5px; background: #DCDCDC;" | '''[[MI]] at presentation'''
-| style="padding: 5px 5px; background: #F5F5F5;" | Present with [[hemorrhage|hemorrhagic]] complications. [[Epidemiological]] investigation may reveal a pattern of disease [[transmission]] by an insect vector. Virus isolation and serological investigation serves to distinguish these [[viruses]]. Confirmed history of previous [[yellow fever]] [[vaccination]] will rule out [[yellow fever]].
+| style="padding: 5px 5px; background: #F5F5F5;" | 1
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" | '''Others'''
+| style="padding: 5px 5px; background: #DCDCDC;" | '''Prior [[PCI]] or prior [[MI]]'''
-| style="padding: 5px 5px; background: #F5F5F5;" |[[Viral hepatitis]], [[leptospirosis]], [[rheumatic fever]], [[typhus]], and [[mononucleosis]] can produce [[signs]] and [[symptoms]] that may be confused with [[Ebola]] in the early stages of [[infection]].
+| style="padding: 5px 5px; background: #F5F5F5;" | 1
+|-
+| style="padding: 5px 5px; background: #DCDCDC;" | '''Prior [[PCI]] or prior [[MI]]'''
+| style="padding: 5px 5px; background: #F5F5F5;" | 1
+|-
+| style="padding: 5px 5px; background: #DCDCDC;" | '''Stent diameter less than 3mm'''
+| style="padding: 5px 5px; background: #F5F5F5;" | 1
+|-
+| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Paclitaxel]]-eluting stent'''
+| style="padding: 5px 5px; background: #F5F5F5;" | 1
+|-
+| style="padding: 5px 5px; background: #DCDCDC;" | '''[[CHF]] or [[LVEF]] less than 30%'''
+| style="padding: 5px 5px; background: #F5F5F5;" | 2
+|-
+| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Saphenous vein]] graft [[PCI]]'''
+| style="padding: 5px 5px; background: #F5F5F5;" | 2
 |-
 |}