Case Introduction

A 65-year-old male patient is presented to the clinic with a chief complaint of chest pain. He has a history of hypertension and hyperlipidemia, and he is currently taking atorvastatin and lisinopril. He is a non-smoker and drinks alcohol socially.

On physical examination, the patient’s blood pressure is 140/90 mmHg, his pulse is 72 beats/minute, and his respiratory rate is 16 breaths/minute. His lungs are clear to auscultation, and his heart rhythm is regular.

An electrocardiogram (EKG) shows ST segment elevation in the inferior leads, which is consistent with an acute inferior wall myocardial infarction (MI). The patient is admitted to the hospital for cardiac catheterization and intervention.

Decision #1

Which medication should be prescribed for the patient to prevent thrombosis and embolization:

• Aspirin
• Clopidogrel
• Ticagrelor

Selected Decision: Ticagrelor

Rationale:

Ticagrelor is a newer antiplatelet agent that has been shown to be superior to clopidogrel in reducing the risk of cardiovascular events in patients with acute coronary syndrome (ACS). In the PLATO trial, ticagrelor reduced the risk of death from any cause, myocardial infarction, and stroke by 9% compared to clopidogrel.

Why not aspirin or clopidogrel?

Aspirin is a less effective antiplatelet agent than ticagrelor or clopidogrel. Clopidogrel is a good antiplatelet agent, but it is less effective than ticagrelor in patients with ACS.

What are the ethical considerations?

The main ethical consideration is the risk of bleeding. Ticagrelor is associated with an increased risk of bleeding compared to clopidogrel. However, the benefit of ticagrelor in reducing cardiovascular events outweighs the risk of bleeding in most patients with ACS.

Communication with the patient

It is important to communicate with the patient about the risks and benefits of ticagrelor before prescribing it. The patient should be aware of the increased risk of bleeding, but they should also be aware that ticagrelor is the most effective antiplatelet agent available for preventing cardiovascular events in patients with ACS.

References

• Bhatt DL, Steg PG, Bélanger F, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;360(24):2066-2076.
• The PLATO Investigators. Ticagrelor versus clopidogrel in high-risk patients with acute coronary syndrome. N Engl J Med. 2011;364(9):814-825.
• American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline on the treatment of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(21):e78-e140.