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Zorluk: ZorPharmacologic Interventions

A 6464-year-old man is preparing for discharge from the cardiac care unit following an anterior ST-segment elevation myocardial infarction (STEMI). On the day of admission, he underwent successful primary percutaneous coronary intervention with the placement of a drug-eluting stent in the left anterior descending artery. His past medical history is significant for type 22 diabetes mellitus, moderate persistent asthma, and osteoarthritis of the knees.

Echocardiography performed prior to discharge demonstrates a left ventricular ejection fraction of 35%35\%. He is currently euvolemic, hemodynamically stable, and completely asymptomatic. Renal function is normal with a serum creatinine of 1.11.1 mg/dL, and potassium is 4.34.3 mEq/L.

He is currently taking aspirin and high-intensity atorvastatin, which will be continued. To optimize this patient's long-term morbidity and mortality, which of the following medications should also be included in his discharge regimen? (Select all that apply)

  1. TicagrelorCevap
  2. LisinoprilCevap
  3. Metoprolol succinateCevap
  4. D
    Diltiazem
  5. E
    Naproxen

Cevap

The correct discharge regimen should include ticagrelor, lisinopril, and metoprolol succinate.
The optimal discharge regimen for a patient following a STEMI complicated by heart failure with reduced ejection fraction (LVEF < 40%40\%) requires multidrug guideline-directed medical therapy. A P2Y12 inhibitor (ticagrelor) must be added to aspirin to complete dual antiplatelet therapy, preventing stent thrombosis. An ACE inhibitor (lisinopril) is indicated to reduce cardiac remodeling and mortality. A beta-blocker proven in heart failure (metoprolol succinate) is also essential for mortality reduction. Notably, cardioselective beta-1 blockers like metoprolol are safe and indicated even in patients with moderate asthma.

Adım Adım Çözüm

1
Analyze the patient's cardiovascular diagnosis and recent procedures.
The patient had an anterior STEMI treated with a drug-eluting stent and now has heart failure with reduced ejection fraction (LVEF 35%35\%).
Establishing the cardiac substrate determines the required components of guideline-directed medical therapy (GDMT).
2
Identify indicated medications for secondary prevention.
Dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor), an ACE inhibitor, and a beta-blocker are essential for post-MI and HFrEF management.
These medication classes have proven mortality and morbidity benefits in this specific patient population.
3
Evaluate the patient's comorbidities against potential medication side effects to identify absolute or relative contraindications.
The patient has moderate persistent asthma and osteoarthritis. A cardioselective beta-blocker (metoprolol succinate) is safe in asthma. NSAIDs (naproxen) are contraindicated post-MI. Non-DHP CCBs (diltiazem) are contraindicated in HFrEF.
Comorbidities frequently alter standard pharmacologic regimens and introduce critical prescribing hazards.

Anahtar Kavram

Guideline-directed medical therapy for post-MI HFrEF includes dual antiplatelet therapy, ACE inhibitors, and beta-blockers. Cardioselective beta-blockers are safe in mild-to-moderate asthma. NSAIDs and non-DHP calcium channel blockers are strictly contraindicated.
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