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Zorluk: ZorPharmacologic Interventions

A 62-year-old man is evaluated in the cardiac intensive care unit after undergoing primary percutaneous coronary intervention (PCI) for an acute anterior ST-segment elevation myocardial infarction. A drug-eluting stent was successfully deployed in the proximal left anterior descending artery. His past medical history is significant for hypertension, hyperlipidemia, type 2 diabetes mellitus, and a transient ischemic attack 2 years ago that presented as right-sided weakness resolving completely within 12 hours.

Vital signs are temperature 37.1°C (98.8°F), blood pressure 118/76 mm Hg, pulse 74/min, and respirations 14/min. Physical examination reveals a normal S1 and S2 with no murmurs, clear lungs to auscultation, and no peripheral edema.

His current medications include intravenous unfractionated heparin, chewable aspirin, high-intensity atorvastatin, and intravenous nitroglycerin. Laboratory studies show a serum creatinine of 1.1 mg/dL, potassium 4.2 mEq/L, and normal platelet count.

The cardiology team is discussing the initiation of a P2Y12 receptor inhibitor to complete his dual antiplatelet therapy regimen. The resident suggests starting prasugrel.

Which of the following features of this patient's clinical profile represents an absolute contraindication to the use of this specific pharmacologic intervention?

  1. A
    Age of 62 years
  2. History of transient ischemic attackCevap
  3. C
    Type 2 diabetes mellitus
  4. D
    Concomitant use of high-intensity atorvastatin
  5. E
    Current administration of unfractionated heparin

Cevap

History of transient ischemic attack
The correct answer is the patient's history of transient ischemic attack. Prasugrel is a potent thienopyridine P2Y12 receptor inhibitor used as part of dual antiplatelet therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention. However, it carries a black-box warning and is absolutely contraindicated in patients with a history of transient ischemic attack (TIA) or stroke. This contraindication is based on trial data showing a significantly increased risk of major bleeding, particularly fatal intracranial hemorrhage, in this subgroup.

Adım Adım Çözüm

1
Identify the patient's clinical situation and the proposed pharmacologic intervention.
The patient is post-PCI for an acute myocardial infarction, and the team proposes initiating prasugrel for dual antiplatelet therapy.
Establishing the clinical context is essential for evaluating the safety and appropriateness of the proposed drug.
2
Review the patient's medical history for potential contraindications to prasugrel.
The medical history includes hypertension, hyperlipidemia, type 2 diabetes mellitus, and a transient ischemic attack (TIA).
Prasugrel carries specific black-box warnings that must be cross-referenced with the patient's comorbidities prior to prescription.
3
Apply pharmacological knowledge regarding prasugrel's contraindications.
Prasugrel is absolutely contraindicated in patients with a prior TIA or stroke.
Clinical trials demonstrated an unacceptably high risk of fatal intracranial hemorrhage when prasugrel is used in patients with a history of cerebrovascular ischemic events.

Anahtar Kavram

Prasugrel is absolutely contraindicated in patients with a history of transient ischemic attack (TIA) or stroke due to a high risk of fatal intracranial hemorrhage.
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Pharmacologic Interventions

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