A 62-year-old man comes to the emergency department due to sudden-onset chest pain. The patient is diagnosed with unstable angina. He undergoes cardiac catheterization and receives a drug-eluting stent to the left circumflex artery. Medical issues include hypertension, hypercholesterolemia, osteoarthritis, and chronic kidney disease. The patient was hospitalized 6 months earlier for upper gastrointestinal bleeding related to ibuprofen use. He is treated with aspirin, prasugrel, lisinopril, atorvastatin, and metoprolol.
Laboratory results are as follows:
Echocardiogram shows a left ventricular ejection fraction of 55%. Which of the following additional therapies is indicated in this patient?

Question

A 62-year-old man comes to the emergency department due to sudden-onset chest pain.  The patient is diagnosed with unstable angina.  He undergoes cardiac catheterization and receives a drug-eluting stent to the left circumflex artery.  Medical issues include hypertension, hypercholesterolemia, osteoarthritis, and chronic kidney disease.  The patient was hospitalized 6 months earlier for upper gastrointestinal bleeding related to ibuprofen use.  He is treated with aspirin, prasugrel, lisinopril, atorvastatin, and metoprolol.
Laboratory results are as follows:
 Echocardiogram shows a left ventricular ejection fraction of 55%.  Which of the following additional therapies is indicated in this patient?

Quizplus · Accepted Answer

Dual antiplatelet therapy (DAPT) (aspirin plus P2Y₁₂ receptor blocker) to prevent stent thrombosis following recent drug-eluting stent placement increases the risk of gastrointestinal bleeding (GIB). This risk is particularly increased among patients with peptic ulcer disease, prior upper GIB, active Helicobacter pylori infection, or age >65. ₁₂ In high-risk patients taking DAPT, proton pump inhibitor (PPI) therapy should be initiated as it significantly decreases the risk of upper GIB. PPI inhibition of CYP219 metabolism may decrease the efficacy of the P2Y₁₂ receptor blocker clopidogrel in preventing stent thrombosis; therefore, when clopidogrel is used, PPIs with relatively strong CYP219 inhibition (eg, omeprazole) should be avoided in favor of those with weaker CYP219 inhibition (eg, pantoprazole). PPI therapy does not appear to affect the efficacy of prasugrel and other P2Y₁₂ receptor blockers (eg, ticagrelor). ₁₂ ₁₂ (Choice A) ACE inhibitor (eg, lisinopril) monotherapy and angiotensin II receptor blocker (ARB) monotherapy have both been shown to reduce proteinuria and slow the progression of chronic kidney disease. This patient is already on lisinopril, and adding an ARB to an ACE inhibitor is not recommended due to unclear additional benefit and an increased risk of adverse effects (eg, hyperkalemia, acute kidney injury). (Choice B) Although niacin can significantly raise serum HDL levels, there is no evidence that the addition of niacin to a statin improves cardiovascular outcomes compared with statin therapy alone. (Choice D) Ranolazine is an antianginal agent typically reserved for stable angina that is refractory to other medical therapy (eg, beta blockers, calcium channel blockers, nitrates) and/or coronary revascularization. It is not currently indicated in this patient. (Choice E) Spironolactone is an aldosterone antagonist indicated for patients with symptomatic heart failure with left ventricular ejection fraction <35%. It is not indicated in this patient with normal left ventricular systolic function. < Educational objective: Prior upper gastrointestinal bleeding (GIB), peptic ulcer disease, active Helicobacter pylori infection, and age >65 increase the risk of upper GIB in patients taking dual antiplatelet therapy (DAPT). Proton pump inhibitor therapy has been shown to decrease the risk of upper GIB in high-risk patients taking DAPT. __________ References: Clopidogrel with or without omeprazole in coronary artery disease. (http://www.ncbi.nlm.nih.gov/pubmed/20925534) ACCF/ACG/AHA 2010 expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on expert consensus documents. (http://www.ncbi.nlm.nih.gov/pubmed/21060077) Expert position paper on the use of proton pump inhibitors in patients with cardiovascular disease and antithrombotic therapy. (http://www.ncbi.nlm.nih.gov/pubmed/23425521)

A 62-Year-Old Man Comes to the Emergency Department Due to Sudden-Onset