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A male patient who was 65 years old performed an appendectomy on March 29, 2018.
On April 3, the patient had sustained chest pain suddenly. He was diagnosed with acute anterior ST-segment elevation myocardial infarction (STEMI), atrial fibrillation, pump function grade I, and did percutaneous coronary intervention (PCI). Then he took postoperative antiplatelet, anticoagulant, and lipid-regulating treatments.
He was discharged on April 12.

1. Perioperative PCI guidelines

Keep in mind that one week after surgery is a dangerous period, and patients are prone to recurrent thrombosis. Attacks within 48 hours or within a week account for 70% to 80%. Heparin is used for at least 48 hours and it usually takes no more than 8 days.

Remember three things:

1) Atrial fibrillation: warfarin (1 ~ 3mg, qd), long-term oral, to prevent stroke.
2) Postoperative PCI: Aspirin (75 to 100 mg, qd) plus clopidogrel (75 mg, qd) for 1 year to prevent stent thrombosis.
3) Atrial fibrillation+PCI: warfarin plus aspirin plus clopidogrel for 1 to 6 months, warfarin plus aspirin or clopidogrel up to one year, and long-term oral warfarin.

Tips:

1) No STEMI contraindication, oral β-blockers (such as metoprolol) within 24 hours, long-term oral ACEI, if necessary, oral spironolactone;
2) STEMI without contraindications, oral statin as soon as possible, regardless of cholesterol levels.

2. Patient’s hospitalization

1) What kind of antithrombotic regimen does PCI take with AF?

Patient condition: postoperative PCI + atrial fibrillation. To prevent stent thrombosis and stroke, the ideal antithrombotic regimen is warfarin plus aspirin plus clopidogrel. Taking into account the risk of bleeding after 3 days of appendicitis in patients, the actual use of warfarin plus clopidogrel dual drug regimen.

In addition, studies have shown that oral warfarin can significantly reduce the incidence of stroke (about 67%), plus aspirin can not further reduce the incidence of stroke and myocardial infarction, but significantly increased the risk of bleeding time.

Tips: warfarin + aspirin + clopidogrel, bleeding risk, can be used to prevent PPIs or H2 receptor antagonists.

2) How long does the warfarin + low molecular weight heparin overlap?

Warfarin exerts anticoagulation by inhibiting the synthesis of vitamin K-dependent coagulation factors II, VII, IX, and X. Warfarin has no effect on activated clotting factors, so it takes 2 to 3 days after taking warfarin to work. Warfarin’s half-life is 36 to 42 hours, and it takes about 10 days to reach steady state.

PCI requires rapid heparin injection anticoagulation. Due to atrial fibrillation, warfarin need to be taken orally as soon as possible after PCI to prevent stroke. The ideal drug regimen is unfractionated heparin or low-molecular-weight heparin + warfarin, which is applied over 5 days of overlap, and heparin is discontinued after the INR reaches the target value (INR 2.0-3.0).

Patients in this case: Warfarin overlapped with low molecular weight heparin for only 3 days, so the INR (1.84) on April 10 did not reach the 2.0 to 3.0 requirement.

3. Patient discharged from hospital

The patient’s discharge diagnosis was:

  • Acute anterior ST-segment elevation myocardial infarction, atrial fibrillation, pump function II
  • Appendicitis
  • Fatty liver
  • Calcification of the prostate

1) Why did the patient not receive β-blockers?

Beta-blockers are beneficial for reducing myocardial infarct size, reinfarction, and ventricular fibrillation, and have a positive effect on reducing mortality in the acute phase. Patients with STEMI who have no contraindications should routinely take oral β-blockers, such as metoprolol, within 24 hours after onset.

The patient has heart failure and can delay or reduce the use of beta-blockers.

2) Both benazepril and spironolactone can cause hyperkalemia and can they be used together?

Benapepril (ACEI) is the first class of drugs that can reduce mortality in patients with heart failure. It is the cornerstone of heart failure and can cause hyperkalemia.

Spironolactone (aldosterone receptor antagonist, potassium-sparing diuretic) can inhibit myocardial remodeling and can significantly benefit patients with heart failure. The most common adverse reaction is hyperkalemia.

Therefore, benazepril should be avoided in combination with spironolactone. However, since benazepril combined with spironolactone can further reduce the mortality of patients with chronic heart failure, the two drugs can be used in combination, but the level of serum potassium needs to be closely monitored.

3) Can the five drugs in the prescription be eaten at the same time?

The specific time of taking drugs must not only consider the impact of food on drug absorption, but also consider the effect of drug treatment time on drug efficacy and adverse reactions.

It is known that foods have no significant effect on the absorption of clopidogrel, spironolactone, and benazepril. To avoid gastrointestinal reactions, they can be taken after breakfast; to minimize the impact of food on warfarin and improve efficacy, take Chinese medicine before going to bed. Farin Sodium and Atorvastatin (Suggested at regular intervals)

4. Correct use of warfarin

1) Common dose

The initial dose is 1 to 3 mg and the maintenance dose is 3 mg.

2) Anticoagulation strength monitoring

The best anticoagulant strength of warfarin is INR 2.0~3.0, and the risk of hemorrhage and thromboembolism are the lowest. Although some scholars believe that elderly patients should adopt a lower INR target value (1.8 to 2.5) when applying warfarin, there is still no large clinical evidence.

3) INR monitoring frequency

After taking warfarin for the first time 2 to 3 days, the INR is monitored daily or every other day until the INR reaches the target value (2.0 to 3.0) for at least 2 days. After that, it is monitored once a week, and stability can be monitored once a month.

4) Dosage adjustment

When the initial dose of INR does not reach the target within 1 week, the dose may be adjusted according to the original dose of 5 to 15% and the INR may be monitored continuously (every 3 to 5 days) until it reaches the target value (2.0 to 3.0).

5. Medication account

1) Monitor INR and serum potassium every month.

2) Always tell your doctor to take warfarin (to avoid interaction) when you see a doctor.

3) Seek medical advice immediately if there is ecchymosis, cyanosis, bleeding gums, epistaxis, black stools, hematuria, myalgia, liver pain, dry cough, etc.

4) Stable diet structure, do not increase nutritional supplements.

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