Reference no: EM133636014
Case: A 79-year-old man was transferred to our department with acute myocardial infarction. He presented with severe chest pain and was in cardiogenic shock. Echocardiography showed a severely reduced left ventricular function. The patient had a longstanding history of coronary artery disease and had received a drug-eluting stent (Cypher) in the LAD (left anterior descending artery) and three drug-eluting stents (Endeavor) in the RCA (right coronary artery) in 2007.
In the following year the patient experienced an acute anterior myocardial infarction due to stent-thrombosis of the LAD. The patient received another 3 drug-eluting stents (DES) (Taxus) in the LAD and 2 DES (Promus) in the RCA.
In 2011 he was again admitted with ST-elevation myocardial infarction. Acute coronary angiography showed again a thrombotic stent occlusion of the LAD. The vessel was reopened, and another DES (Xience) was implanted. Since this time the patient was on long-term antiplatelet therapy with aspirin and ticagrelor.
On October 1, he was admitted to our associated hospital because of neck pain and was diagnosed to have spondylodiscitis. Analgetic and antibiotic treatment was initiated.
The onset of chest pain was on October 11, at approximately 6:00 a.m.
An electrocardiogram was performed at this time and showed acute myocardial infarction.
Immediate coronary angiography revealed thrombotic occlusion of both, the proximal LAD and the proximal RCA requiring implantation of a DES (Xience) in the LAD and a balloon dilatation of the RCA. In order to stabilize the patient an intra-aortic balloon pump was implanted, and the patient was transferred to the Intensive Care Unit. Aspirin and ticagrelor as well as continuous intravenous low molecular heparin were administered.
Since the patient had suffered his 3rd stent thrombosis, a platelet function test was performed.
The effect of aspirin was measured using the PFA 100 test. Collagen/Epinephrine closure time of only 84 sec. was found, which indicated an insufficient antiplatelet effect of aspirin. In order to assess the effect of ticagrelor, the Platelet VASP/P2Y12 test was performed and showed a moderate effect of ticagrelor (Platelet Reactivity Index of 52%).
A further detailed history was undertaken with the treating physician of the referring hospital, which revealed that therapy with ticagrelor had been discontinued 6 days before and that the patient had continuously received ibuprofen 400 mg twice daily for pain relief during the last 10 days.
Identify the possible causes, conditions/reason for admission (e.g., hypotension, bradycardia, increase in serum creatinine, etc.)
What is the possible mechanism of drug interaction.
Type of drug interaction
a. Pharmacokinetics
b. Pharmacodynamics
Why?
What is your advice to the prescriber(s) and/or to the patient?
References used to answer the questions above.
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