Anticoagulation Therapy Clopidogrel, Aspirin, Warfarin Case Study

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Anticoagulation Therapy (Clopidogrel, Aspirin,
Warfarin)Case Study 1
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Patient History

• 82-year-old male
• Long history of atrial fibrillation
• Prior TIA
• 4 months ago
• Placement of paclitaxel-eluting stent (3.5 x 18
  mm) in right coronary artery

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Initial Presentation

• Patient presents to ED with
• Weakness
• Shortness of breath
• Tarry, black stools
• Medication regimen
• Aspirin, clopidogrel, warfarin
• Atorvastatin, ramipril, metoprolol
• Hemoglobin 7.2 g/dL
• Aspirin, clopidogrel, and warfarin stopped to
  reduce risk of bleeding

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Patient Management

• Patient undergoes endoscopy
• Diagnosis Gastric ulcer
• Ulcer is successfully cauterized
• Patient is started on PPI

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Question

• How would you manage this patient?
• Resume aspirin, clopidogrel, and warfarin
• Resume aspirin and clopidogrel
• Resume clopidogrel and warfarin
• Place patient on heparin plus aspirin and
  clopidogrel

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Question
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Management of Subacute ThrombosisCase Study 2
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Patient Presentation/Management

• 67-year-old male
• Presents with unstable angina
• Undergoes placement of sirolimus-eluting stent in
  LAD
• Patient discharged on
• Aspirin, clopidogrel, statin, ACE inhibitor,
  beta-blocker

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Patient Status

• Clopidogrel is stopped at 6 months
• He remains on other drugs, including aspirin

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Clinical Course

• Two months after stopping clopidogrel, patient
  presents to ED
• Severe, crushing chest pain radiating to left
  arm
• Nausea
• Diaphoresis
• Symptoms had persisted for 4 hours at time of
  presentation
• ECG shows acute anterior STEMI

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Question

• What would you recommend for this patient?

a. Lytic therapy b. Catheterization/angiography
c. Resumption of clopidogrel therapy
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Question
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Angiography
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Evaluation/Treatment

• Angiography reveals
• Thrombus occluding proximal LAD at the site of
  previous stent
• LAD recanalized and restented
• Clopidogrel therapy is restarted

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Question

• Would you recommend restarting clopidogrel at a
  loading dose of

a. 300 mg? b. 600 mg? c. 900 mg?
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Question
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Antiplatelet Therapy inPatient with Chest
PainCase Study 3
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Patient History

• 70-year-old male
• Presents to ED with chest pain
• Pain has persisted on and off for 3 hours
• Pain is mid-sternal, radiating to jaw
• Some shortness of breath

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EKG Findings
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Treatment

• In ED, patient is managed with
• Clopidogrel (loading dose of 600 mg)
• Aspirin
• IV nitroglycerin
• IV metoprolol
• He continues to have chest discomfort
• Additional treatment
• Heparin (4000 units)
• Eptifibatide (bolus dose IV drip)

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Angiography
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Question
What is the best next step in managing this
patient?

• a. Insert IABP (intra-aortic balloon pump)
• b. Proceed to CABG surgery immediately
• c. Wait 5 days, and then operate
• d. Proceed with left main stenting

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Question
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New Developments in Antiplatelet Therapy