Case Reports
Monday, November 13, 2023
01:00 PM–02:30 PM
Abstract
Introduction: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y
12 inhibitor is recommended in patients with acute coronary syndrome (ACS) or post PCI to prevent stent thrombosis. Prasugrel is contraindicated in patients with history of stroke/TIA and not recommended in patients 75 years or older or weight <60 kg. This case report describes prasugrel use in a 76-year-old Veteran with history of TIA.
Case: A 76-year-old male with a history of heart failure (HF), ACS, coronary artery bypass surgery, peripheral arterial disease, and TIA presented with non-ST elevation ACS. The patient underwent PCI receiving three drug eluting stents. Within days of starting DAPT (aspirin and ticagrelor), he reported rash, blisters, and itching, subsiding three days after self-discontinuation of ticagrelor. Prior pharmacogenomic testing revealed CYP2C19 *1/*2 diplotype, deeming him an intermediate metabolizer and therefore poor candidate for clopidogrel. Cilostazol was briefly considered but ruled out because of its HF contraindication. After a comprehensive risk/benefit discussion with the patient, he consented to prasugrel.
Discussion: Prasugrel is more effective than clopidogrel/ticagrelor in reducing cardiovascular morbidity and mortality in patients with ACS undergoing PCI. However, patients aged 75 years or older are at increased risk of fatal and intracranial bleeding with the risk of intracranial hemorrhage significantly increased in patients with a history of stroke/TIA. Given our patient’s extensive cardiovascular history and recent stents, concerns regarding clopidogrel efficacy, and inability to tolerate ticagrelor, patient-centered shared decision making led to the use of prasugrel despite these risks. This patient has tolerated prasugrel for four months without any issues.
Conclusion: Prasugrel use in patients 75 years and older and/or with history of stroke or TIA or weight <60 kg should generally be avoided. However, it may be considered in extreme cases when DAPT is warranted without alternatives.
Presenting Author
Madeline Armstrong B.S.University of Tennessee College of Pharmacy
Authors
Robert Parker Pharm.D.
University of Tennessee Health Science Center
Ally Ponder Pharm.D., M.P.H.
Memphis VA Medical Center
Georges Ephrem M.D.
University of Tennessee College of Medicine
Kelly C. Rogers Pharm.D.
University of Tennessee College of Pharmacy